David G. Stewart, Ph.D. Seattle Pacific University

1. Using Evidence Based Interventions with Culturally Diverse Children and Families: Evidence and Strategies for Engagement David G. Stewart, Ph.D. Seattle Pacific University

2. Objectives • Rationale for attending to diversity in EBP implementation • Methods for maintaining adherence and fidelity AND engagement • Culturally competent collaboration • Cultural Hypothesis Testing • MI strategies • Case Examples • Programmatic • Individual

3. 2001 Surgeon General Report on Mental Health: Ethnic Representation in Randomized Clinical Trials for Bipolar Disorder, Schizophrenia, ADHD and Depression Percentage of All Clinical Trial Participants (N=10,000) 14.00% Percentage of Clinical Trial Participants where Ethnicity was Identified (n=5,009) 12.00% Percentage in the U.S. Population 10.00% 8.00% Percent Represented 6.00% 4.00% 2.00% 0.00% African-American Hispanic or Latino Asian/Pacific Islander American Indian/ Alaska Native Ethnic Group All published reports 1986-2000

4. Disproportionality

5. Ethnic/ Cultural Characteristics of Clients Served 1998-2004 (N=195) • Biracial • Multiracial • Gay • Lesbian • Bisexual • Transgendered • Samoan • Tongan • European • Russian • Bosnian • Korean • Vietnamese • Cambodian • Thai • African American (70%) • White (21%) • Hispanic • Mexican American • Puerto Rican • Peruvian • Native American • African • Eritrean • Ethiopian • Somali • Kenyan

6. Determining Fit of ESTs to Diverse Clients • Are language, culturally specific variants available? • Does EST have external /ecological validity? • Has EST been developed with a representative sample? • Does diagnostic specific EST address cultural variants in diagnosis? • Does the EST include orientation/engagement strategies?

7. Principles of Culturally Competent Intervention

8. Continuum of Addressing Diversity Cultural Sensitivity Cultural Competence Cultural Specificity

9. Culturally Competent Practices • Eight practices based on strategies developed by Bernal, et al. (1995) to promote culturally competent interactions. The principles are designed to be measurable by an objective rater. • Use language that enhances comfort and understanding. Avoid use of jargon or “loaded terminology.”

10. 2. Acknowledge and use similarities and differences between individuals to shape and enhance the relationship. Culture is a central aspect of our assessment and intervention. The therapist’s culture as it relates to the process of engagement, clinical effectiveness and retention in treatment must be included early in the therapeutic process. Clients must be given an opportunity to discuss their feelings about the therapist’s culture (race, gender, SES, etc.). When clients are uncomfortable in even discussing differences or similarities, the therapist will raise and test hypotheses about his/her cultural impact with supervisors and colleagues.

11. 3. Encourage ethnic/cultural symbols, concepts, sayings, stories as part of the dialogue. The therapist who has genuine knowledge of a client’s cultural experience will use elements of that culture in creating therapeutic metaphors, examples and throughout the therapeutic dialogue. Therapists will also elicit this material from clients by asking about topics such as, family stories and multigenerational parenting practices. A therapist may also use language, symbols and stories from his own background to enrich the therapeutic dialogue.

12. 4. Demonstrate knowledge of and respect for cultural values and practices. The therapist is aware of cultural norms in a variety of contexts including: personal space, time orientation, gender roles, generational roles, dress, emotional expression and religion. The therapist gains credibility by accepting these values and avoids making unnecessary judgments based on culture-bound behavior.

13. 5. Set collaboration goals that are consonant with culture and context: Any conflict between therapeutic needs and cultural norms is a topic of active discussion and problem solving.

14. 6. Support values and strengths from culture of origin. Strong religious affiliation, support of extended family, resilience and humor are examples of the types of cultural strengths to be utilized and enhanced.

15. 7. Adapt methods to culture. Bernal, et al. (1995) describe specific techniques that culturally competent therapists use to enhance existing treatment models these include: "modeling" to include culturally consonant traditions; "cultural reframing" of problems as partly reflecting economic and social realities; cultural hypothesis testing; use of genograms; "cultural migration/change dialogue"

16. 8.Consider cultural context in implementation. All aspects of treatment specifically address the context of culture and social conditions on the client. Key factors include; societal pressures/conditions; social supports and relationship to community; economic and social context of intervention; ethnic labeling/disproportional sanctions; stress of migration or acculturation. Bernal G, Bonilla J, Bellido C (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology. 23(1): 67-82.

17. Hispanic Stress Inventory: Parenting Factor Thought children want independence before ready. My children have seen too much sex on TV/movies. I thought my children not receiving good education. My children haven't respected my authority as should. My children have gotten bad school reports/grades. Thought about son/daughter living independently. My children have talked about leaving home. I thought my children used illegal drugs. My children influenced by bad friends. Difficult to decide how strict to be with children. Cervantes, Padilla & Salgado de Snyder (1991)

18. Hispanic Stress Inventory: Immigration Factor Since I don't know English, hard interacting with others. I felt pressured to learn English. Thought I'd be deported if went to social/govt. agency. Due to poor English people treated me badly. Due to poor English, hard dealing with daily situations. I feared consequences of deportation. I felt guilty leaving family/friends in home country. Felt never regain status/respect I had in home country. I've been discriminated against. I've been questioned about my legal status. Haven't forgotten war deaths of friends/family. Haven't forgotten last few months in my home country.

20. Motivational Interviewing as a Culturally Competent Practice • Evidence of increased effectiveness in ethnic minority populations • Inherent client-centered and directive approach • Culturally specific adaptations • Flexibility in implementation within or before other EST’s • Directly addresses ambivalence

21. Here are some of the ideas behind MI… 1. Motivation for change honors the wisdom within the client instead of trying to force a therapist’s wisdom upon a client. 2. The client is seen as a person rather than a problem. The client identifies and processes his or her own feelings about change. Some tribes take this level of respect to new heights and call clients by their clan relation such as sister, uncle, etc.

22. Here are some of the ideas behind MI… 3. The counselor provides humble, respectful, and active guidance in helping the client examine and move forward with their feelings about change. 4. Persuasion is not an effective method because trying to convince others to change often invites them to argue against change.

23. Here are some of the ideas behind MI… Venner, K.L., Feldstein, S.M. & Tafoya, N. (2006). Native American motivational interviewing: Weaving Native American and western practices. Albuquerque: Authors 5. The counseling style is peaceful and draws the wisdom out from inside of the client. 6. Readiness to change is not steady. Instead, it changes depending on the client’s internal and external environments (i.e. social relationships, job status, financial status, family and friends, community). 7. The therapeutic relationship is more of a partnership, rather than an expert talking to a patient.

24. Measuring Confidence to make a Change 1. “On a scale of 0 – 10, where 0 is not at all confident and 10 is extremely confident, how confident are you that you could make a change in (specific behavior) now? 2. “What makes you choose (number client chose) rather than a 0?” “What does it mean to be a (number client chose)? 3. “What would it take to bump you up a few notches to a (choose a number two or three higher than originally given)?

26. Exploring Pros and Cons to Elicit Change Talk Goals: To provide an opportunity for your clients to actively discuss how they feel about a specific behavior. To provide the counselor an opportunity to understand the client’s point of view about the pros and cons of the behavior, to reinforce change talk, and to support the client.

28. Here are some of the ideas behind MI… 1. Motivation for change honors the wisdom within the client instead of trying to force a therapist’s wisdom upon a client. 2. The client is seen as a person rather than a problem. The client identifies and processes his or her own feelings about change. Some tribes take this level of respect to new heights and call clients by their clan relation such as sister, uncle, etc.

29. Here are some of the ideas behind MI… 3. The counselor provides humble, respectful, and active guidance in helping the client examine and move forward with their feelings about change. 4. Persuasion is not an effective method because trying to convince others to change often invites them to argue against change.

30. Here are some of the ideas behind MI… 5. The counseling style is peaceful and draws the wisdom out from inside of the client. 6. Readiness to change is not steady. Instead, it changes depending on the client’s internal and external environments (i.e. social relationships, job status, financial status, family and friends, community). 7. The therapeutic relationship is more of a partnership, rather than an expert talking to a patient. Adapted from: Rollnick, S. & Miller, W. R. (1995) What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334

31. Engagement, Accountability and Cultural Competence in the MST/FIT Model

32. Cultural Competence • Interventions are designed to empower families to intervene in multiple systems, including ones that may be perceived as coercive or punitive • 2. Interventions are provided by therapists who are : • Culturally Competent and often • Culturally Matched • 3. Interventions are designed that are respectful of and consistent with the cultural values of the family and community. • 4. Cultural strengths are recognized and developed as keys to change

33. Social-Ecological Model Neighborhood School Peers Caregivers Teen Siblings

34. School Attached to school Achieving-moving toward graduation Peers Positive Peers Peers are involved in + activities Caregivers High Monitoring Consistent Discipline Low Conflict Expressed Warmth Teen Positive Behavior Neighborhood Multiple adult(+) models - Recreational Activities Jobs/ training - Religious/Spiritual Guidance

35. Keys to Engagement • Treatment team responsible for engagement and provide services unconditionally • Therapists are strength-focused • Family members full collaborators; therapists align with parents • Services individualized and comprehensive • Services provided in natural ecology (i.e., family home)

36. Creating an Environment of Alignment and Engagement “My family and the therapist were honest and straightforward with each other.” “The sessions were lively and energetic.” “Family members were not engaged in power struggles with the therapist.”

37. Alignment and Engagement “My family and the therapist worked together effectively.” “My family and the therapist had similar ideas about ways to solve problems.” “Family members and the therapist agreed upon the goals of the sessions.” “A lot was accomplished during the therapy sessions.”

38. Case Presentation • H., a 15 y.o., Eritrean-American male • Marijuana Dependence, Ecstacy & Alcohol Use • Oppositional Defiant Disorder • History of thefts, domestic violence, truancy and noncompliance with probation • Attending alternative school due to disruptive behavior and truancy • At Risk Youth Petition

39. Case Presentation • Lives with Mother and 2 brothers • Brother # 1 age 18, in college headed for dental school • Brother #2 age 16, incarcerated for arson • Parents divorced, father in town, alcoholic, little contact

41. Cultural Role Hypothesis: Mother’s cultural beliefs about parenting and women’s roles preclude taking strong stance with defiant teenage son • Discuss with Mother in individual session • Migration Dialogue • Meet with cultural consultant • Discuss with older son • Partially Confirmed • Engagement of family improved • H. became involved in positive community activities • Brother increased activity with H. • Engage older brother, uncle and community members to assist mother in parenting • Therapy strategies with Mother to reframe some cognitions around past events and parenting and learn to tolerate the distress of parenting 3 teenage sons alone

42. Ethnic Identity Development Hypothesis: H. desperately wants to identify with American culture and takes on an exaggerated role modeled by peers (gang-wannabes) • Discuss with family in session • Discuss with cultural consultant • Confirmed: Youth is struggling with issues of identity development and acculturation • Dissociated from negative peers • Successful enrollment in public school • More integrated identity development • Provide positive African American role models • Exit alternative school and enroll in public school with diverse African American peer group • Enroll in activities to foster positive identity development- Martial arts, African language course, African American History group