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

1. 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. How to Culturally Adapt Evidence-Based Treatments (EBTs): Tools, Guidelines, and Clinical Examples Guillermo Bernal, Ph.D. University of Puerto Rico

2. 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

3. Arriving at Cultural Adaptation …

4. 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)

5. Approaches to Cultural Adaptation Collaborative

6. Culturally Adapted Process of Cultural Adaptation EBT 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 Cultural Adaptation Process

7. 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).

8. (Bernal, Bonilla, & Bellido 1995)

9. 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

10. 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

11. 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)

12. 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

13. 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

14. 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 está la gota en la piedra hasta que le hace un hoyo

15. 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)

16. 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

17. 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)

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

19. Methods • Lau- Bottom up Approach • Survey: Sampled 146 Chinese immigrant parents of children aged 4-17 sampled for perceived acceptability of common parent training strategies before adapting Incredible Years Parenting program

20. Methods Generating knowledge and collaborating with stakeholders • Hwang • Focus Groups- Mental health professionals experienced serving the Asian community • Interviews – Community Leaders • Traditional Chinese Medicine (TCM) practitioners • Buddhist monks • Nuns • Spiritual and religious Taoist masters • Discussed: • Different manuals and interventions • Cultural adaptations • How they have individually adapted treatments • What aspects of treatment manual would work as is and what would need modifications • Once manual was revised follow-up focus groups were conducted

21. Methods • Domenech-Rodríguez & Wieling- Focus groups used to guide adaptations • Exploring language and content elements • Parenting practices • Expectations • Factors facilitate and increase or recruitment and retention • Barrera and colleagues- Focus groups conducted with participants of Pilot Study to receive feedback on the program • Interviews were recorded transcribed, and analyzed for major themes and trends

22. Methods Benefits of Participatory Approach : • “Offers the group/community an element of empowerment, collaboration, and emancipation …helping them to normalize their experiences and to network” (Domenech-Rodríguez & Wieling 2004) • Incorporating community members facilitated “buy-in” to the treatment to potential consumers • Built a sense of community • Strengthen referral networks • Focus group collaboration helped reduce personal, clinician, and agency specific biases (Hwang, 2009)

23. Methods • Pilot testing manual-testing the culturally adapted intervention and using the feedback from therapists and clients who participated in the clinical trial • Hwang- weekly supervisions with PI during pilot test offers additional insight • Interviews with consumers • Was the treatment effective? • What was most beneficial? • Recommendations

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

25. 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

26. Methods Instruments • Barrera-Simplified user-friendly Informed Consent Form (ICF) that combined the consent and HIPAA forms into one document • “When working with ethnically diverse populations, finding appropriate measures also includes finding measures that have been normed with the population under study or submitting existing measures to the rigors of adaptation (Domenech-Rodríguez & Wieling, 2004).” Accommodations: • Interian-The majority of participants preferred to have outcome measures (i.e. BDI-S, BAI, and PHQ- 15) administered by clinicians versus completing self-report

27. 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

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. References Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for cultural adaptation and development of psychosocial treatments with Hispanics. 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, 27, 207-230. Bernal, G., Domenech Rodriguez, M. (2009). Advances in Latino Family Research: Cultural Adaptations of Evidence-Based Interventions. Family Process, 48, 2,169-178. Bernal,G., Jiménez-Chafey, Domenech Rodríguez, M. (in press) Cultural Adaptation of Evidence-based Treatments for Ethno-cultural Youth. Domenech-Rodríguez, M., & Weiling, E. (2004). Developing culturally appropriate, Evidence-Based Treatments for interventions with ethnic minority populations. In M. Rastogin & E. Weiling (Eds.), Voices of Color: First person accounts of ethnic minority therapists. (pp. 313-333). Thousand Oaks: Sage Publications. Griner, D. Smith, T. (2006) Culturally adapted mental health intervention: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training,43(4),531-548. Hwang, W.-C. (2006). The Psychotherapy Adaptation and Modification Framework: Application to Asian Americans. American Psychologist, 61, 702-715. Interian, A., Allen, L., Gara, M., & Escobar, J. (2008). A Pilot study of Culturally Adapted Cognitive Behavior Therapy for Hispanics with Major Depression. Cognitive Behavior Practice, 15, 67-75. Rosselló, J., & Bernal, G. (1999). The efficacy of cognitive-behavioral and interpersonal treatments for depression in Puerto Rican adolescents. Journal of Consulting and Clinical Psychology, 67, 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). Washington, DC, US: American Psychological Association. Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53, 440-448.