How to Culturally Adapt Evidence Based Treatments (EBTs): Tools, Guidelines, and Clinical Examples

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

• Approaches to Cultural Adaptations • Adaptation Process • Elements of Cultural Adaptations • Examples of Cultural Adaptations in Ethnic Minority Research and Practice • Principles of Cultural Adaptations

Arriving at Cultural Adaptation …

Issue in need of intervention Available interventions?

If yes  Adaptation Needed?

If yes 

Definition of 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)

Approaches to Cultural Adaptation Top Down Bottom Up

Cultural Adaptation Process

Process of Cultural Adaptation Translation of Protocol Forward, Back Translation Panel of Experts Equivalence Criteria Conceptual Framework Expert Review of Protocol Session by Session Changes Focus Groups In-depth Interviews – Experts, Participants Culturally Adapted EBT

Cultural Considerations

The combination of (emic and etic) perspectives we espouse assumes that while the behaviors targeted by the intervention are exhibited across cultures, how persons understand those behaviors and how willing they are to engage in the process of therapy to change the problematic behavior may differ by cultural groups

(Domenech Rodríguez & Wieling 2004).

Ecological Validity Model

Language Context Persons Methods Culturally Sensitive Elements Metaphors Goals Content Concepts

Elements/dimensions of treatment and criteria for evaluating cultural sensitivity in clinical interventions Elements Language

Culturally syntonic

Criteria for Cultural Sensitivity

Do patients understand language, idioms, & words used?

Persons

Ethnic/racial similarities & differences client & therapist

Metaphors

Symbols & concepts shared; Is the patient comfortable with the similarity (or difference) in the ethnicity of the therapists?

Are sayings or “dichos” common to ethnic group part of the intervention?

Content

Cultural, social, economic, historical, & political knowledge (e.g., values, traditions) Does the patient feel understood by the therapist? Does the patient feel that the therapist respects his/her cultural values (e.g., familismo, respect, personalismo, gender roles)?

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Elements/dimensions of treatment and criteria for evaluating cultural sensitivity in clinical interventions Elements Concepts •

Treatment concepts consonant with culture & context (dependence vs. independence)

Goals •

Transmission of positive adaptive cultural values; support of adaptive values from culture of origin

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? 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?

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Elements/dimensions of treatment and criteria for evaluating cultural sensitivity in clinical interventions Elements Methods •Development & cultural

adaptation of treatment methods .

Criteria for Cultural Sensitivity •Are the treatment methods framed within

adaptive cultural values of the patient?

•Does the patient agree with the methods of

treatment?

Context •Consideration of

changing contexts in assessment during treatment or intervention: acculturative stress, phase of migration, social supports & 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?

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Examples

• Rosselló and Bernal – CBT and IPT for Puerto Rican adolescents with depression • Hwang and colleagues – CBT for Asians with depressive symptoms • Lau and colleagues – Incredible Years Parenting Program for Cantonese/Mandarin speaking parents referred for ineffective parental discipline or child behavior problems

Examples

• Barrera,Toolbert, Strycker, Osuna – Mediterranean Lifestyle Program for a Lifestyle Change Intervention for Latinas with Type 2 Diabetes • Domenech-Rodríguez & Wieling – Parent Management Training Oregon model adapted for Mexican Americans with children who exhibit behavior problems • Interian, Allen, Gara, & Escobar – CBT for Latinos with major depression • Jacqueline S. Gray – Suggested adaptations for American Indian clients

Language

Interventions conducted in the patients 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 nubilidad = 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)

Language

• Barrera: Language Layers – Re-named program ¡Viva Bien!

– Use of Spanish in meetings and in printed materials – Focus groups held (2 in English, 2 in Spanish) – Employment of bilingual/bicultural staff – Presentations and classes led in Spanish bilingual screens – Diabetes group education sessions were initiated and conducted by a bilingual physician

Persons

Ethnic match is associated with less premature termination, dropouts, & better outcomes (Sue, 1998).

• Rosselló & Bernal – Treatment delivered by Puerto Rican therapists – Sensitized to different, racial, socio-economic status and cultural aspects • Hwang – Treatment delivered by therapist experienced working with Asian families

Metaphors

• Rosselló & Bernal - Symbols of Puerto Rican culture – Positive role models were represented in posters in the waiting area – Ideas expressed in culturally relevant metaphors/sayings during therapy • Homework vs. Personal project – Dichos/Sayings • Mas vale tarde que nunca • De los errores se aprende • No hay mal que por bien no venga • No hay mal que dure 100 años, ni cuerpo que lo resista • Tanto da la gota en la piedra hasta que le hace un hoyo

Content

• Interian – Somatic Symptoms • Therapeutic techniques shown to have an effect on physical symptoms were taught – Attention given to values that may impede change • Familismo inhibits person from taking time for themselves • Reframed- Time for oneself=Improve depression=Improve Family functioning – Common values • Respeto (Respect) – Adaptation - Assertiveness training to elicit respect from others • Poniendo de su parte (Putting one’s part) – Interpersonal styles • Overtly warm and positive interactions emphasized (simpatia)

Concepts

• Rosselló & Bernal – Differentiation (or Independence) as healthy – Enmeshment (or Dependence) as pathological – Intergenerational Conflicts • Lau-Cognitive restructuring to help parents cope with children's bid for autonomy and school-related problems – Psychoeducation and communication skills added to model to increase positive parental involvement in children’s schooling

Goals

• Lau – Incorporated parents’ concern for child’s school performance in therapy by providing communication skills for parents to address teachers and offer ideas for parents involvement in child’s schoolwork in spite of language barriers (i.e. reduce child “screen” time)

Methods

• Flexibility in adapting methods of treatment to client needs – Didactic vs. Process Approach – Family participation

Methods

Accommodations • Slowing the pace of skill lessons • Increasing dosage of behavioral rehearsal • Emphasis on role playing to introduce novel skills (Lau 2009)

Methods

• Interian- Ethnocultural Assessment – CBT should be complemented with ethnocultural evaluation to guide cultural adaptations necessary • Number of years in the U.S.

• Adaptation to migration • Location of family members • Changes in family support • Impact of migration

Context/Culture

• Rosselló & Bernal –

Familismo

is one of the strongest cultural values of Puerto Ricans and Hispanics –

Simpatia

–

Respeto

– Personal space – Parental authority – Present time orientation – Socioeconomic Contexts • Barrera – Inclusion of family members in some intervention activities – Use of ethnic foods and music – Cooking demonstrations with recipes modified using common Latino staples by Latina dietician – Exercise routine Latin music salsa steps

Context/Culture

• Therapy should include willingness of the therapist to open up and collaborate with the client – Asking about traditional greetings – How do they wish to be addressed?

Familiarity with cultural norms

• Group Therapy process for grief within a tribe where name of the deceased is not to be mentioned – Discussion occurred but in the context that respected their culture and allowed for mourning – Focus was on crafts, artwork done in honor of the person (Gray, 2009)

Context/Culture

• Location- Expanding Access – Barrera- Provision of classes at accessible community venues – Interian-Intervention provided in Primary Care Clinic • Centrally located • Facilitated transportation – Hwang- Focus groups held at Asian focused community mental health centers with staff (mental health professionals) experienced serving Chinese American and other Asian Americans – Benefits: • Ensure that the program developed would be sustainable

Principles for Adapting of EBTs

• Applying the criteria of ecological validity – Is the environment as experienced by the patient/client the same as the therapist assumes it is experienced in treatment?

– Does the target population require a treatment adaptation?

• Evidence of engagement in treatment • Evidence of remaining in treatment • Role of acculturation, language, culture, race

Principles for Adapting of EBTs

• Use of a conceptual frameworks to identify key elements in the adaptation • Culturally centering the intervention – Contextualizing content • Contextually grounding all procedures • Enhancing engagement into treatment

Principles of Adapting EBTs

• Develop procedures to involve target population in the process of adapting EBTs – In-depth interviews, focus groups, use of Opinion Leaders, etc. • Documentation of all adaptations

Conclusions

• Considerable agreement in the dimensions that are culturally adapted – Despite different frameworks, cultural groups, and contexts • Importance of engaging the community that is the target of the intervention in all phases of the project • Cultural adaptations are likely to enhance engagement, outcomes, and sustainability of interventions

Resources

• Many examples illustrated in this presentation are from a forthcoming book: Bernal, G. & Domenech Rodríguez, M. (In Preparation).

Cultural Adaptation: Tools for evidence based practice with diverse populations

. Washington DC: American Psychological Association Press

Other Resources

Bernal, G. & Domenech Rodríguez, M. (2009). Advances in family research with Latinos,

Family Process.

Gallargo, M. Evidence based practice in psychology.

Professional Psychology: Research and Practice

– A special issues that will be published in 2009

References

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Journal of Abnormal Child Psychology

, 2367-82.

Bernal, G., Bonilla, J., & Santiago, I. J. (1995). Psychometric properties of the BDI and the SCL-36 in a Puerto Rican sample (in Spanish).

Revista Latinoameriana de Psicología

,

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, 207-230. Bernal, G., Domenech Rodriguez, M. (2009). Advances in Latino Family Research: Cultural Adaptations of Evidence-Based Interventions. for Ethno-cultural Youth.

Domenech-

Family Process, 48,

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Griner, D. Smith, T. (2006) Culturally adapted mental health intervention: A meta-analytic review.

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Hwang, W.-C. (2006). The Psychotherapy Adaptation and Modification Framework: Application to Asian Americans.

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Interian, A., Allen, L., Gara, M., & Escobar, J. (2008). A Pilot study of Culturally Adapted Cognitive Behavior Therapy for Hispanics with Major Depression. Puerto Rican adolescents.

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Rosselló, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in 734-745.

Rosselló, J., & Bernal, G. (2005). New Developments in Cognitive-Behavioral and Interpersonal Treatments for Depressed Puerto Rican Adolescents. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (2nd ed.). (pp. 187-217). Sue, S. (1998). In search of cultural competence in psychotherapy and counseling.

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