INTRODUCTION

Treatment outcome studies in the discipline of social work, psychology, and psychiatry have demonstrated the efficacy and effectiveness of differential psychotherapy approaches in addressing the psychological needs of individuals across the life span (Beutler & Crago, 1991; Hibbs & Jensen, 1996). Throughout the last four decades, scholar-practitioners have engaged in a professional quest to find evidence to support the efficacy of psychotherapy in ameliorating an array of clinical symptoms and levels of distress in identified patient or client populations. La Roche and Christopher (2009) contend that this quest began largely as a response to Eysenck’s (1952) review of the treatment outcome literature, from which he concluded that the success rate of psychotherapeutic models of treatment was not greater than spontaneous remission. Eysenck’s (1952) review set the stage for systematic therapy outcome studies aimed at demonstrating the efficacy and effectiveness of clinical interventions and selected psychotherapy approaches. Evidence-based practice and the current state of empirically supported psychosocial therapies are a by-product of this quest.

While it is evident that treatment outcome studies and the development of evidence-based psychosocial therapies have contributed to significant improvement in the delivery of clinical and mental health services (see Whaley & Davis, 2007), clinical researchers (e.g., Bernal, Jimenez-Chafey, & Domenech Rodriguez, 2009; Hwang, 2009; Rossello & Bernal, 1999) have raised concerns about the applicability of evidence-based practices to the psychosocial treatment of culturally diverse patient populations. At the root of the concern is the issue of whether evidence-based treatments developed within a particular cultural and linguistic context are appropriate for ethnocultural patient populations that do not share the same cultural values, mores, and language of the patient or client cohort for whom the treatment was developed. Because culture and specific socioethnographic variables influence the effective delivery of clinical services and the diagnostic and treatment process (see González & González-Ramos, 2005), the noted concern must always be in the forefront of competent psychosocial practice. In addition to this concern, some mental health scholars (Atkinson, Bui, & Mori, 2001; Miranda, Bernal, Lau, Kohn, Hwang, & LaFromboise, 2005) have documented the absence of ethnic and racial minority sample groups in studies of evidence-based treatments. The recruitment and retention of ethnically, racially, and linguistically diverse sample populations in psychotherapy research studies are of vital importance for the cultural adaptation of evidence-based practices.

This chapter presents an overview of evidence-based practice with ethnically diverse clients. Predicated on an integrative understanding of evidence-based practice and cultural competency in mental health and clinical care settings and the importance of intersectionality as the guiding theoretical perspective for effective delivery of patient-centered services, selected conceptual frameworks for the cultural adaptation of evidence-based treatments will be presented. Culturally adapted cognitive-behavioral therapy (CBT) will also be highlighted as an exemplar of evidence-based treatment for ethnic and racially diverse patient populations.

EVIDENCE-BASED PRACTICE AND CULTURAL COMPETENCE IN MENTAL HEALTHCARE

Evidence-based practice—to a significant extent—is guided by Paul’s (1967) seminal practice-informed research questions: “What treatment, by whom, is most effective for this individual, with that specific problem, and under which set of circumstances?” (p. 111). Consistent with the evidence-based movement in medicine (see Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000), evidence-based practice in the professional disciplines of social work and psychology has as its major aim the improvement of patient outcomes—across specific psychological and social domains—through the integration of clinical practice with relevant research and patient values. Directed by this aim, the American Psychological Association (APA) Presidential Task Force on Evidence-Based Practice has defined this type of practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences” (APA Presidential Task Force on Evidence-Based Practice, 2006, p. 273). This definition—with its emphasis on the clinical expertise of the practitioner in the context of client characteristics, culture, and preferences—resonates well with the value base of the helping professions. Evidence-based practice is a collaborative process for making treatment decisions (see Drisko & Grady, 2012, 2018) and its purpose, according to the Task Force, “is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship and intervention” (p. 284). If this purpose is to be implemented by clinical practitioners and systems of care, the individual and cultural characteristics, preferences, and values of ethnically and racially diverse populations must converge with the overall intent of evidence-based practice: improved patient outcomes and effective delivery of psychosocial treatment. The convergence will be facilitated by understanding the need for cultural competence in the provision of mental health and clinical services.

The need for cultural competence in the provision of psychosocial services is justified by two important factors: (a) the increasing cultural diversity and multicultural population within the United States and (b) the well documented ethnic, racial, and linguistic disparities in the utilization of mental health services (Bernal & Scharron-del-Rio, 2001). From a clinical and organizational perspective, Sue and Torino (2005) define cultural competence in the following manner:

Culture, the major variable in culturally competent practice, is a complex and multidimensional construct that directly influences the process of psychotherapy and the understanding of the human condition. It has not always received, however, adequate attention as a construct that is of paramount importance in the development of culturally sensitive psychotherapy and culturally competent mental health services (Guarnaccia & Rodriguez, 1996; La Roche & Christopher, 2009). Evidence-based practice with ethnic minorities or ethnically and racially diverse clients must be guided by the recognition that culture is a phenomenon that impacts the bio-psychosocial functioning of the human organism across time and space. In acknowledgment of the role that culture plays in the development and implementation of evidence-informed psychosocial interventions, the APAPresidential Task Force on Evidence-Based Practice (2006) has articulated the following definition of this construct:

The integration of evidence-based practice and cultural competence can lead to the implementation of culturally sensitive psychotherapy in clinical settings. Drawing on the work of Hall (2001) on psychotherapy research with ethnic minorities, La Roche and Christopher (2009) note that: “Cultural sensitive psychotherapy is the tailoring of psychotherapy to specific cultural groups, so that persons from one group may benefit more from a specific type of intervention than from interventions designed for another cultural group” (p. 398). Culturally sensitive psychotherapy is composed of three interrelated domains. The first domain is composed of carefully defined ethnic, racial, and cultural factors that are unique to a specific patient population. The second domain encompasses the constellations of characteristics that are unique or more prominent in certain cultural groups relative to others. The last domain includes culturally sensitive clinical interventions that are targeted to address the needs of an identified culturally diverse patient group. Evidence-based practices that are adapted or created to meet the mental health or psychosocial needs of the ethnically diverse should include these noted domains.

INTERSECTIONALITY, EVIDENCE-BASED PRACTICE AND CULTURALLY COMPETENT CLINICAL CARE

Recent research (see Araújo, Oliveira, & Araújo, 2018; Turan et al., 2019) on health and mental health disparities underscores the importance of individual social identities—such as race, ethnicity, gender, socioeconomic status—on treatment outcomes. The examination of these social identities in combined form—within the context of a socio-political-economic environmental context—is vital for understanding the social determinants of health and the negative treatment outcomes that often impact marginalized and oppressed populations. Intersectionality, as a theoretical perspective, provides the conceptual underpinnings required for such an examination. It is useful for understanding how different forms of privilege and oppression exist simultaneously in shaping an individual’s experiences in the social world and as a recipient of health or mental health services. Importantly, it also helps practitioners and clinical scholars to see that perceived and disparate socio-cultural-economic forces (e.g., race, gender, class) are mutually dependent and co-constitutive (see Bowleg, 2012; Jackson, Williams, & Vander Weele, 2016). Developed by legal scholar Kimberlé Crenshaw, intersectionality draws attention to the “multidimensionality of marginalized subjects’ lived experiences” (Crenshaw, 1989, p. 139), and Dill and Zambrana (2009) have identified it as a “systematic approach to understanding human life and behavior that is rooted in the experiences and struggles of marginalized people” (p.4).

In implementing evidence-based models of mental health treatment with diverse patient populations, it is important to consider how the combined effects of racism, discrimination, poverty and gender differences produce treatment inequalities and access to timely and critical care. Viruell-Fuentes et al. (2012), for example, have noted how racism yields social and economic inequities that, in turn, become a fundamental cause of physical and emotional disease. Emerging research appears to suggest that there is a correlation between perceived discrimination and lower levels of physical and emotional well-being and detrimental health behaviors among immigrant groups—such as Hispanics, Black immigrants and Asians (see Perez, Fortuna, & Alegría, 2008; Ryan, Gee, & Laflamme, 2006). Incorporating, therefore, the conceptual principles of intersectionality in the provision of both culturally competent and evidence-based mental health care may serve to reduce the health-related stigma that is often experienced by patient populations who experience perceived discrimination. Weiss and Ramakrishna (2006) have defined health-related stigma as “a social process or related personal experience characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group identified with a particular health problem” (p. 536). Models of evidence-based practice, therefore, must be informed by both the tenets of cultural competence and the transactional relationship that exists between health and mental health treatment outcomes and stigma. Operationalizing this noted interrelationship in practice will ensure that the principles of intersectionality inform the delivery of humane and effective care.

CONCEPTUAL FRAMEWORKS FOR THE CULTURAL ADAPTATION OF EVIDENCE-BASED TREATMENTS

Integrating culturally competent practice with evidence-informed psychosocial therapies is a complex task. The integration, however, is not impossible—and it may serve to provide a systematic approach to treatment that takes into account the sociocultural and socioeconomic context of ethnically diverse patients. Bernal et al. (2009) argue that the integration can be achieved through the use of cultural adaptation procedures. They define cultural adaptation as “the systematic modification of an evidence-based treatment … 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” (p. 362). Cultural adaptation serves as a unifying bridge between scientis-practitioners who state that the psychosocial problems of ethnically diverse patients should primarily be treated with new treatment approaches (see Comas-Díaz, 2006) and those scholars (see Elliot & Mihalic, 2004) who believe that existing psychosocial treatments should be tested, unchanged, with culturally diverse populations before embarking on any type of adaptation task.

A number of conceptual frameworks (e.g., Bernal, Bonilla, & Bellido, 1995; Hwang, 2006, 2009) have been developed with the intent of facilitating the integration of cultural competence and evidence-based treatments, thereby making psychotherapy or psychosocial treatment culturally malleable for patient populations of diverse ethnic, racial, and linguistic backgrounds. Rogler, Malgady, and Rodriguez’s (1989) framework for culturally competent mental health research provides the seminal domains on which current cultural adaptation psychotherapy frameworks rest. Rogler et al. (1989) recommended improving cultural understanding in mental health research, practice, and treatment innovation along five domains: (a) cultural factors in the emergence of a clinical/mental health presenting problem, (b) help seeking and service utilization, (c) factors that may affect an accurate diagnosis, (d) therapeutic and treatment issues, and (e) posttreatment adjustment of the patient. Hwang (2006) notes that this seminal framework is important in providing effective treatment to ethnic minorities because “it underscores the temporal sequence of problem development in relation to service delivery and highlights areas where culture is likely to play a role” (p. 703).

CULTURALLY ADAPTED CBT

CBT is based on the premise that thoughts, actions, and feelings are closely related (see Beck, Rush, Shaw, & Emery, 1979). CBT is an evidence-based, short-term therapy approach for the treatment of depression, anxiety, and other related mental health and psychosocial disorders. To treat depressive feelings, this treatment approach attempts to identify those thoughts and actions that influence these feelings. In the treatment of depression, the primary aims of CBT are: to diminish depressive feelings, shorten the time the identified client feels depressed, teach alternative ways of preventing depression, and increase the person’s sense of self-control over their life. Treatment is directed at assisting the identified client to understand how thoughts influence mood, how daily activities influence mood, and how interactions with other people influence mood as well.

Recent reviews of the literature (see Miranda et al., 2005; Voss Horrell, 2008) on the impact of evidence-based mental healthcare on ethnic minorities provide support for the effectiveness of CBT for African American, Hispanic, and Asian American patients suffering from anxiety and depressive disorders. Culturally adapted CBT approaches are also effective in reducing symptoms of distress among ethnocultural patient populations. Wood et al. (2008), for example, documented via a detailed case study how cultural modification of CBT can lead to positive outcomes for Mexican American students who suffer from anxiety disorders. In their study, Wood et al. (2008), integrated the following cultural competence principles in their adaptation of CBT: (a) spend time learning about the client’s cultural practices, acculturative status, migration history, language proficiencies and preferences, and other relevant background history; (b) respect the client’s and the family’s conceptualization of mental illness and its treatment to increase acceptance of CBT techniques; (c) establish CBT goals that are valued by the client and family to improve the working relationship; (d) actively collaborate with school staff to alleviate parental apprehension; (e) provide an orienting session early on to increase family understanding and participation; (f) learn about the cultural context of parenting to facilitate engagement in CBT; (g) engage the extended family in the child’s CBT treatment; (h) align CBT techniques with family cultural beliefs and traditions to enhance commitment to treatment; (i) consider whether culturally based conversational norms are masking poor adherence to treatment; and (j) remain attuned to the role of acculturation gaps in children’s adjustment problems, but consult with cultural experts before addressing this topic with families. The integration of these principles with an evidence-based model of treatment increased the probability of a positive treatment outcome for an ethnically diverse client group that underutilizes mental health services and is more likely to drop out of treatment prematurely.

In a pilot study of a 12-session, culturally adapted CBT for Hispanics with major depression, Interian, Allen, Gara, and Escobar (2008) reported a 57% mean reduction of depressive symptoms at posttreatment among patients who completed the intervention. Cultural adaptations that were made in the treatment protocol included: (a) the use of an ethnocultural assessment, which involved inquiring about the patients’ number of years in the United States, their adaptation to the migration, whereabouts of family members and changes in social support; (b) providing the treatment in Spanish including the phraseology commonly used by Hispanics to describe therapeutic phenomena; and (c) allowance for the centrality of the family in treatment. Based on the findings of the study, Interian et al. (2008) note that cultural adaptations to existing treatments may be clinically beneficial, and they recommend that clinicians complement CBT with an ethnocultural assessment.

Similar to the study by Interian et al. (2008), Kohn, Oden, Munoz, Robinson, and Leavitt (2002) adapted a manualized, 16-week cognitive-behavioral group therapy intervention for depressed, low-income, African American women. Adaptation of the CBT group intervention took place along two domains: structural and didactic. Adaptations at the structural level included: (a) limiting the group to African American women, (b) keeping the group closed to facilitate cohesion, (c) adding experiential meditative exercises during treatment and a termination ritual at the end of the 16-week intervention, and (d) changes in some of the language used to describe CBT techniques. For instance, rather than using the term “homework,” the group participants preferred the term “therapeutic exercises.” At the didactic level four culturally specific sections of content were added to the therapy modules: (a) creating healthy relationships, (b) spirituality, (c) African American family issues, and (d) African American female identity. At termination of the intervention, women in the group exhibited a significant decrease in their depressive symptoms as measured by the Beck Depression Inventory (BDI).

The cited studies provide a level of evidence for the effectiveness of culturally adapted CBT in reducing symptoms of depression and anxiety in some ethnocultural patient populations. While the noted studies are primarily applicable to Hispanic and African American patients, some published case studies would seem to suggest that culturally adapted CBT may be the treatment of choice for other ethnically diverse populations such as Japanese clients (see Toyokawa & Nedate, 1996) and Orthodox Jews (see Paradis, Friedman, Hatch, & Ackerman, 1996). As a treatment model, culturally adapted CBT is illustrative of a treatment approach that is informed by both research evidence and cultural competence. The model also demonstrates the type of integrative and complementary relationship that can exist between empirically supported therapies and the reality of culture.

CONCLUSION

The integration of science with the phenomenon of culture and social context are equally important in the development, testing, and implementation of evidence-based practices. If this integration is overlooked in clinical research and in the delivery of clinical services, clients from diverse ethnic, racial, and linguistic backgrounds may be placed at risk for receiving psychosocial care that is not adequate or appropriate. Cultural adaptation frameworks—in conjunction with the conceptual underpinnings of intersectionality—must be employed to evaluate the appropriateness of evidence-based models of psychosocial treatment. The psychotherapy adaptation frameworks highlighted in this chapter—together with intersectionality as a theoretical perspective—serve to bridge the gap between evidence-based therapies and cultural competence. As demonstrated by the cited studies on the effectiveness of culturally adapted CBT, the literature on evidence-based treatment with ethnocultural patients is increasing and points to positive treatment outcomes. The positive treatment outcomes with culturally adapted evidence-based therapies are welcome in an era where there is growing recognition that mental health services must mirror the diverse and changing demographic profile of the nation. Cultural competence and evidence-based practice are two critical issues that will continue to shape clinical services in the near future. This chapter has addressed both issues and the need for their integration.

DISCUSSION QUESTIONS

REFERENCES