Cultural Adaptation of Evidence-Based Practices
The Hogg Foundation recently completed a three-year initiative to improve mental health services for populations of color in Texas. In 2006, the foundation awarded grants to community mental health providers across Texas to adapt delivery of mental health services to reflect the cultures of populations of color. Grantees reported success with the adaptation of several different evidence-based practices and plan to continue to use them. Based on their experiences, culturally adapted services are more likely to yield greater positive outcomes for ethnic minorities.
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Benefits of Evidence-Based Practices
In the United States, the development of evidence-based practices has been a major force in improving the quality of mental health services by emphasizing treatment approaches with research support. Here are examples of evidence-based practices:
- Depression: For both adults and children, cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) have been shown to effectively address the range of depressive disorders. CBT centers on modifying the patients' maladaptive thinking patterns and behaviors that lead to and perpetuate depression. IPT assists the patient with working through problematic relationships that may be fueling the depression.
- Anxiety disorders: For both adults and children, the two most effective types of psychotherapy for anxiety disorders are behavioral therapy and cognitive therapy. Behavior therapy works by teaching the patient techniques, such as breathing and relaxation, and/or by exposing the patient to anxiety-provoking stimuli in a graduated fashion. Cognitive therapy focuses on identifying and modifying patients' maladaptive thought processes that can lead to and perpetuate anxiety. Exposure therapy, a variation of CBT, is the most effective psychotherapy for specific phobias and posttraumatic stress disorder. Exposure therapy involves the basic components of CBT plus exposure to the phobic object or traumatic memories and related images in order to reduce symptoms. There are manualized, child-specific CBT models as well for treating children, such as trauma-focused CBT (TF-CBT).
- Attention deficit-hyperactivity disorder: For children, the combination of medication and behavior therapy often yields the best results. For example, behavior management training provides practical skill-building for both the child and parent to better manage problem behaviors and can be effective as a first-line or single intervention. Curriculum-based protocols are available.
- Externalizing disorders: For children with disruptive or oppositional behaviors, behavior management training provides information and skill building for both child and parent to change unwanted child behavior. There are a number of curriculum-based protocols for use with either children or adolescents, with additional components for parental skill building.
Consumers who participate in psychotherapy research tend to be Anglo, female, educated and middle or upper class. A key criticism of evidence-based practices is that research rarely considers cultural and ethnic/racial factors. Many studies fail to specify the ethnic/racial composition of their treatment samples or examine their findings by those variables. Of those that do include this information, few include adequate representation of ethnic minorities.
Cultural Disparities in Mental Health Services
Texas is a "majority-minority" state, meaning that just over half of the state’s population is ethnic and racial minorities, according to the U.S. Census Bureau. The four major groups of color in the U.S. – African Americans, Asian Americans, Latinos, and Native Americans – are well-represented in Texas.
There are important ethnic and racial differences in how people view mental illness, recognize their own distress, communicate their distress to others, seek help, and participate in treatment. Ethnic and racial differences in people's views of mental illness and treatment should be incorporated into any treatment approach if it is to be beneficial for different ethnic/racial groups.
But public and private mental health systems have been slow to address the needs of these growing populations. As a result, people of color experience significant disparities in their access to mental health services, the quality of services they receive, and the outcomes of those services. Members of ethnic minority communities have less access to mental and physical health care. They are more likely to be uninsured, which means they have less access to preventative care and prescription medications, higher rates of avoidable hospitalizations, and later-stage diagnosis of health problems.
When ethnic minorities do have access to mental health services, the care they receive is less likely to meet their needs. A psychological treatment that is effective for one ethnic/racial group may not work with all groups. Even when a psychological treatment is beneficial for all ethnic/racial groups, its delivery should be tailored to meet the unique cultural experiences of different groups. That’s because culture impacts how people:
- Identify and communicate mental distress.
- Explain the causes of mental health conditions.
- Perceive mental health providers.
- Respond to mental health treatment.
Cultural Adaptation of Services
Cultural adaptation is the process of adjusting the delivery of mental health services to be consistent with the consumer’s culture. Simply put, cultural adaptation is the process of modifying mental health service delivery at the administrative, service delivery and clinician levels to make it culturally competent. Cultural competence is the integration and transformation of knowledge, information and data about individuals and groups of people into specific clinical standards, skills, service approaches, techniques and marketing programs that match the individual's culture and increase the quality and appropriateness of mental health care and outcomes.
In mental health, cultural competence occurs in when cultural issues are acknowledged and addressed at all levels of an organization.
- Administrative level: cultural competence impacts access, service utilization, staff professional development and quality improvement throughout the organization. Administrative strategies to promote cultural competence include development of an agency cultural competence plan, community involvement in needs assessment and planning, ethnic and racial diversity of board and staff, among others.
- Service delivery level: cultural competence fosters engagement and retention of populations of color in treatment. Some examples of service delivery strategies are incorporation of spiritual beliefs into the treatment of culturally different clients, provision of services in the client's primary language through bilingual staff or interpreters, and use of culturally and linguistically appropriate assessment instruments.
- Clinician level: cultural competence impacts the therapeutic relationship between the clinician and consumer, supporting the consumer's participation in treatment.
In culturally adapted service delivery, adjustments are made at the administrative, service delivery, and clinician levels to reflect the cultural knowledge, attitudes and behaviors of the target population. Culturally adapted care should be culturally competent care. Frank, ongoing assessment of the population's needs and the organization's response to those needs is essential, as is creative, thoughtful translation of those assessment findings into action at the administrative, service delivery and clinician levels.
There is no one way to culturally adapt mental health services. The best way to do so depends on the cultural background and needs of the treatment population and the resources of the provider organization. Frank, ongoing assessment of the population's needs and the organization's response to those needs at the administrative, service delivery, and clinician level is essential, as is creative, thoughtful translation of those assessment findings into action.
Program Officer Rick Ybarra, (512) 471-9154