Culturally informed Evidence Based Practice

1. Culturally informed Evidence Based Practice Daryl Fujii Ph.D., Honolulu and the Multicultural/Diversity Committee (2009-2010) VA Psychology Training Council Contact persons: Daryl Fujii Ph.D., Honolulu (Daryl.Fujii@va.gov) Rachael Guerra Ph.D., Palo Alto (Rachael.Guerra@va.gov)

2. Multicultural/Diversity Committee Committee 2009-2010 Loretta E. Braxton Ph.D., Durham, (Co-Chair) Linda R. Mona Ph.D., Long Beach (Co-Chair) Lenora Brown Ph.D., St. Louis Daryl Fujii Ph.D., Honolulu Rachael Guerra Ph.D., Palo Alto Jamylah Jackson Ph.D., North Texas Tina Liu-Tom Ph.D., Honolulu Monica Roy Ph.D., Boston Miguel Ybarra Ph.D., San Antonio Jay Morrison Ph.D., San Francisco (Postdoc) Velma Barrios, Greater Los Angeles (Intern)

3. Overview • Presentation will provide a brief overview of literature on Evidence Based Practices (EBPs) and ethnic minorities • Purposes • Dispel the myth that there are no studies on EBPs and ethnic minorities • Provide recommendations for modifying EBPs for ethnic minorities

4. Agenda • APA Policy Statement on Evidence-Based Practice (EBP) in Psychology (2006) • Literature review on EBP with ethnic minorities • Justification of cultural adaptations • Types of cultural adaptations • Examples of recommendations for cultural adaptations • Summary • Exercise

5. Learning Objectives • Learn how APA position on EBPs are consistent with culturally informed treatment • Learn how the emerging literature supports the effectiveness of EBPs with ethnic minorities • Cultural adaptations incremental validity to treatments • Learn strategies to adapt EBPs to improve effectiveness with ethnic minority groups

6. APA Policy Statement • “Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”

7. APA Policy Statement • Best Research Evidence • Evidence should be based on systematic reviews, reasonable effect sizes, statistical significance, and a body of supporting evidence • Should not assume interventions that have not been studied in controlled trials are ineffective • New developments should be rigorously evaluated

8. APA Policy Statement • Clinical Expertise • “Important to integrate the best research evidence with clinical data within the context of the patient’s characteristics and preferences to deliver services that have a high probability of achieving the goals of treatment.” • Integral is “awareness of the limits of one’s knowledge and skills and attention to the heuristics and biases…that can affect clinical judgment.” • Understand how “own characteristics , values, and context interact with those of the patient.”

9. APA Policy Statement • Patients Characteristics, Values, and Context • Interventions “most effective when responsive to the patient’s specific problem, strengths, personality, sociocultural context, and preference.” • “A central goal of EBPP is to maximize patient choice among effective alternative interventions/”

10. APA Policy Statement: Clinical Implications • Clinician determines applicability of research conclusions to individual patient. • A patient may require “decisions and interventions not directly addressed by available research.” • Applicationof research requires “probabilistic inferences” • “Ongoing monitoring of patient progress and adjustment of treatment as needed are essential to EBP.”

11. Literature Review • Miranda et al (2005) • EBPs effective with different minority groups and children and adults for a wide range of mental disorders and problem behaviors (e.g. depression, anxiety, family problems) • largest most rigorous literature support EBPs for depression for African-Americans and Latinos with size effects equal or greater to Whites • less data for Asians, however, findings promising

12. Literature Review • Huey & Polo (2008) • in children, EBP interventions produced positive treatment effects of medium magnitude • no compelling evidence that cultural adaptations promote better clinical outcomes for ethnic minority youth

13. Literature Review • Griner & Smith (2006) meta-analysis • found moderate size effect for culturally competent interventions versus traditional mental health interventions d=0.45 • findings provide support for incremental validity of cultural competent interventions • participant characteristics: • older subjects had higher effect sizes than younger • ethnicity of client did not moderate results • Hispanics low levels of acculturation profited greatly from culturally competent interventions

14. Literature Review • Griner & Smith (2006) (cont.) • type of adaptations: • homogenous samples demonstrated stronger effect sizes than mixed populations • no matching of therapists had larger effect sizes compared to those when matching attempted • client matched on language (if other than English) outcomes twice as effect than those that did not match for language

15. Are Cultural Adaptations Justified? • Given effectiveness of some EBPs with ethnic minority samples, are cultural interventions necessary? • Lau (2006) • Cultural adaptations should be judiciously applied, warranted if: • (a) clinical problem is unique to an ethnic group • (b) clients from a specific ethnic community are found to respond poorly to an EBP approach

16. Are Cultural Adaptations Justified? • APA Multicultural Guidelines (2003) • “Psychologists encouraged to: • “acquire an understanding of the ways in which experiences (e.g. ethnocentrism, racism, sexism, ableism, homophobia) relate to presenting psychological concerns…including…worldview” • “be aware of the role that culture may play in the establishment and maintenance of a relationship between the client and therapist.”

17. Are Cultural Adaptations Justified? APA Multicultural Guidelines (cont.) • “Multiculturally sensitive psychologist should: • “recognize that culture-specific therapy (individual, family, and group) may require nontraditional interventions and should strive to apply this knowledge in practice.” • “examine traditional psychotherapy practice interventions for their cultural appropriateness… to expand these interventions to include multicultural awareness and culture-specific strategies.”

18. Are Cultural Adaptations Justified? • Whaley & Davis (2007) • Movement from efficacy to effectiveness studies can be enhanced by using cultural adaptations • Therapeutic engagement and treatment retention major challenges in delivery of evidence-based practices, cultural competency may be a solution • Cultural adaptations consistent with need to maximize external validity

19. Types of cultural adaptationsSue et al. (2009) • Method of delivery: • Language • Varying interpersonal style (e.g. show respeto to clinician) • Providing a cultural context for interventions (Andres-Hyman et al., 2006) • (e.g. use of ethnic foods, blessing for the day, unity circle, didactic orientation or classroom format to reduce stigma)

20. Sue et al. (cont.) • Involve generic applications that can implemented across treatment modalities and theoretical orientations • Method of delivery (goals): • intended to make intervention more culturally consistent • increase credibility of treatment provider • make treatment understandable to client

21. Sue et al. (cont.) • Content: • discussion of or dealing with cultural patterns, immigration, minority status, racism, specific cultural background experiences, in the intervention • Increase understandability and credibility of intervention

22. Samuels, Schudrich & Altschul (2008) • Developed a toolkit for modifying EBPS to increase cultural competence http://ssrdqst.rfmh.org/cecc/ • Accommodations • Modifying delivery of EBP so that it can be utilized with a particular culture (e.g. language, interpreters) • Adaptation • Changing structure of program to fit needs and preferences of a culture

23. Cultural Factors that may impact mental health services • View of Mental Illness • Holistic health view • Attribution • Degree of stigma • Social Positioning • Discrimination • Equality • Stereotypes • Acculturation • Formality (Samuels et al. 2008) • Social positioning

24. Cultural Factors that may impact mental health services • Lifestyle • Housing • Education • Social class • Development through life • Age • Gender • Dating • Marriage/Divorce • Sexual activity/sexual orientation (Samuels et al. 2008)

25. Cultural Factors that may impact mental health services • Health • Use of drugs and alcohol • Specific health problems • Family/kin relationships • Family constellation • Disciplining children • Power in relationships • Communication (Samuels et al. 2008)

26. Cultural Factors that may impact mental health services • World view • Religion • Spirituality • Concepts of Self • Locus of Control • Outlook • Time Conceptualization (Samuels et al. 2008)

27. Access: structural components that may require modification for cultural groups • Location • Transportation • Building (Samuels et al. 2008)

28. Access: process/operational components that may require modification for cultural groups • Hours • Language • Payor • Provider • Intervention-specific training and materials • Who is included in treatment (Samuels et al. 2008)

29. Recommendations for Cultural AdaptationsBeardsley & Wilson (2009) Motivational Interviewing -OARS • Open ended questions • Some cultures may prefer more directive approach with clinician as “expert” • Open-ended questions may feel too ambiguous and people may not know how to answer • Consider immigration status and how that might impact questioning

30. Beardsley & Wilson (2009) (cont.) • Affirmations • Some cultures may find affirmations embarrassing • Affirmations may not feel appropriate if consumer is somatizing illness • It might be more affirming to praise the family, spouse, or children • Being genuine is critical

31. Beardsley & Wilson (2009) (cont.) • Reflective listening • May be important to offer directive approaches, rather than simply repeating back information presented • Might consider local and other culturally appropriate reflective statements • Summarizing • Summarizing may be confusing because it is too linear • Circular approach like storytelling may be more appropriate

32. Hays (2009) Integrating Evidence-Based Practice, CBT and Multicultural therapy • ADDRESSING (Hays, 2008) • Age/Generational • Developmental Disabilities • Disabilities Acquired Later in Life • Religion and Spiritual Orientation • Ethnic and Racial Identity • Socioeconomic Status • Sexual Orientation • Indigenous Heritage • National Origin • Gender

33. Hays (2009) Culturally Responsive CBT (cont.) • Assess the person’s and family’s needs with an emphasis on culturally respectful behavior. • Identify culturally related strengths and supports. • Clarify what part of the problem is primarily environmental and what part is cognitive with attention to cultural influences. • For environmentally based problems, focus on helping the client to make changes that minimize stressors, increase personal strengths and supports, and build skills for interacting more effectively with the social and physical environment.

34. Hays (2009) Culturally Responsive CBT (cont.) • Validate clients’ self-reported experiences of oppression. • Emphasize collaboration over confrontation, with attention to client-therapist differences. • With cognitive restructuring, question the helpfulness (rather than the validity) of the thought or belief.

35. Hays (2009) Culturally Responsive CBT (cont.) • Do not challenge core cultural beliefs. • Use the client’s list of culturally related strengths and supports to develop a list of helpful cognitions to replace the unhelpful ones. • Develop weekly homework assignments with an emphasis on cultural congruence and client direction.

36. Summary • APA clinical guidelines empowers clinicians to use their judgment in determining the effectiveness of EBP with ethnic minorities in the absence of available research and to make adaptations. When implementing such adaptations, monitoring of progress is essential.

37. Summary • Current literature supports effectiveness of some EBPS with ethnic minorities. • Literature also provides evidence for incremental validity of cultural adaptation. • Cultural adaptations are most effective for older, less acculturated clients who have poor command of English.

38. Summary (cont.) • Cultural adaptations can target: • method of delivery (e.g. language, interpersonal style, cultural context) • content (specific to client)

39. Summary • Important cultural considerations include: • Views of mental illness • Social positioning • Lifestyles • Common illnesses and health behaviors • Use of drugs and alcohol • Family/kin relationships • World view

40. Summary • Components that affect access to services • structural components • location, transportation, building • process/operational components • hours , language, pay • provider, interventions • who included in treatment

41. Summary (cont.) • Cultural adaptations increase credibility of therapist and understandability/credibility of the intervention • Clinicians should be familiar with growing literature on EBPs in ethnic minorities, particularly as it relates to their clientele and interventions.

42. Exercise • Pick an Evidence Based Practice • Select an ethnic minority group (age and gender optional) • What are the implicit values of the therapy and how does this interface with values of the selected ethnic minority? • What adaptations could be made in the delivery or content of intervention? • What accommodations or adaptations could be made to increase cultural competence? • Which aspects of Hays’ recommendations can be applied to the cultural adaptation?

43. References • Andres-Hyman et al. (2006): Culture and clinical practice: Recommendations for working with Puerto Ricans and other Latinas in the United States • APA (2006): Evidence-based practice in psychology • APA (2003): Guidelines for multicultural education, training, research, practice, and organizational change for psychologists • Beardsley & Wilson (2009): Introduction to motivational interviewing (presentation)

44. References • Griner & Smith (2006): Culturally adapted mental health intervention: A meta-analytic review • Hays (2009): Integrating evidence-based practice, cognitive –behavioral therapy, and multicultural therapy: Ten steps for culturally competent practice • Huey & Polo (2008): Evidence-based psychosocial treatments for ethnic minority youth: A review and meta-analysis

45. References • Lau (2006): Making the case for selective and directed cultural adaptations of evidence-based treatment: examples from parent training • Miranda et al. (2005): State of the science on psychological interventions for ethnic minorities • Samuels et al. (2008) Toolkit for modifying evidence-based practices to increase cultural competence http://ssrdqst.rfmh.org/cecc/

46. References • Sue et al. (2009): The case for cultural competency in psychotherapeutic interventions • Whaley & Davis (2007): Cultural competence and evidence-based practice in mental health services