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Cultural Adaptation • Selected Annotated Bibliography

This page contains references, abstracts, and, where available, links for recent research articles on collaborative care and its implementation. Please note that where links are provided, subscription to the journal may be required to access the article. (No link was found if there is none listed.) Articles are organized by topic.

• Cultural Competence

» Rationale & Overviews
» Guidelines
» Assessing Cultural Competence
» Developing Cultural Competence

• Evidence-Based Practices (EBPs)

» Rationale & Overviews
» Guidelines
» Implementation Issues
» Specific EBPs

• EBPs and Populations of Color

» Overviews
» Cultural Adaptations

Cultural Competence

Rationale & Overviews

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care.
Public Health Reports, 118, 293-302.
Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care. Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care. Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.

Davis, K. (1997). Consumer Driven Standards and Guidelines in Managed Mental Health for Populations of African Descent: Final Report on Cultural Competence. Rockville, MD: Center for Mental Health Services.
The accurate diagnosis, prevention, or efficacious treatment of mental illness in any population requires in-depth and unbiased knowledge of the individual's culture in conjunction with knowledge about the illness presented. Clinical intervention methods, models, or skills that are not based in cultural competency fail to reflect what is known about the relationship between culture, mental illness, help seeking, recovery, and social policy. Culturally incompetent clinical services are unacceptable, unethical, and prima facie evidence of malpractice and educational deficit. The development of managed care has illustrated the extent to which effective services is contingent on cultural competency. Meeting the needs of consumers of African descent, who have a mental illness, requires managed care plans to include cultural competency in the design, delivery, and evaluation of services and outcomes. Without cultural competency, access to mental health care for consumers of African descent will be limited; costs will outweigh profits; quality will be lacking; and poor outcomes will stimulate demand for additional services. The standards and guidelines that are included in this report are designed to assist health care plans, policy makers, and providers in their efforts to design, finance, and deliver effective services to consumers of African descent who have mental illness.

Guarnaccia, P. J., & Rodriguez, O. (1996). Concepts of culture and their role in the development of culturally competent mental health services.
Hispanic Journal of Behavioral Sciences, 18(4), 419-443.
Reviews different ways that culture has been used in developing the notion of culturally competent mental health services and provides an enhanced definition of culture through a critical review of these ideas. The authors discuss different dimensions of culture that emerge as important issues in the development of bilingual/bicultural psychiatric programs. Specific topics discussed include culture as language, as ethnic identity, as material signs, as events and celebrations, and as shared values; culture and views of mental illness, and acculturation; and the role of social factors in structuring subcultures. A multifaceted definition of the influences of culture on the assessment of clients in culturally competent mental health programs is provided. The issues raised in this review are illustrated with case examples from an evaluation of 3 inpatient bilingual/bicultural psychiatric programs created in a metropolitan area to provide services to severely mentally ill Hispanics. The authors note that in the development of culturally competent mental health services, program planners need to move beyond a simplistic view of culture as creating a physical atmosphere and hiring people who speak the language to incorporate in a more detailed way the multiple dimensions of culture.

Iijima Hall, C. C. (1997). Cultural malpractice: The growing obsolescence of psychology with the changing U.S. population. American Psychologist, 52(6), 642-651.
With the changing demographics occurring in the United States, psychology must make substantive revisions in its curriculum, training, research, and practice. Without these revisions, psychology will risk professional, ethical, and economic problems because psychology will no longer be a viable professional resource to the majority of the U.S. population. In particular, this article discusses the need for psychology to address issues of ethnicity/culture, gender, and sexual orientation.

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Mollen, Debra, Ridley, Charles R., Hill, Carrie L. (2003). Models of multicultural competence: A critical evaluation. In Handbook of multicultural competencies: In counseling & psychology. Thousand Oaks, CA: Sage Publications, Inc., 21-37.
Multicultural counseling competence has taken its place among the most important constructs in applied psychology. Researchers, scholars, and practitioners no longer debate the necessity and significance of having this type of competence. Instead, they now assume it. Numerous publications and conference presentations concerned with training, practice, and the development of models underscore the importance of the construct. The development of models of multicultural competence reflects the advance of scholarship in this specialty. A number of models have been developed, and we are prompted to revisit them in an effort to critically evaluate their merits and shortcomings. In this chapter, we analyze two major models, eight secondary models, and four implicit models of multicultural counseling competence. Although other models exist, we have chosen a cross section of models that we believe is representative of the field. We distinguish major models from secondary models in that the former are much more elaborate than the latter, and they exert more influence on the field. In addition, we examine models that are not explicitly identified as models of multicultural competence but have implicit assumptions about multicultural competence. This chapter is organized into four major sections. In the first section, we describe our criteria for evaluating the major models. In the second section, we describe and critique two major models. In the third section, we describe eight minor models, followed by general critique. In the fourth section, we discuss and critique implicit models. Finally, we offer implications for further research, scholarship, and practice.

Sue, S. (2003). In defense of cultural competency in psychotherapy and treatment. American Psychologist, 58(11), 964-970.
Cultural competency guidelines and policies are being widely established. Yet some critics have challenged the evidence for cultural competency and the lack of efficacy studies that demonstrate its outcomes. Various positions are examined that discuss cultural competency research. They include the need for more resources for research, scientific practices that overlook ethnic research findings, fruitfulness of theory-driven rather than population-based research, problems in defining cultural competency as a technique, and development of policies in the absence of research. Implications of these positions are discussed.

Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53(4), 440-448.
The characteristics involved in cultural competency in psychotherapy and counseling have been difficult to specify. This article describes attempts to study factors associated with cultural competency and addresses 3 questions. First, is ethnic match between therapists and clients associated with treatment outcomes? Second, do clients who use ethnic-specific services exhibit more favorable outcomes than those who use mainstream services? Third, is cognitive match between therapists and clients a predictor of outcomes? The research suggests that match is important in psychotherapy. The cultural competency research has also generated some controversy, and lessons learned from the controversy are discussed. Finally, it is suggested that important and orthogonal ingredients in cultural competency are therapists' scientific mindedness, dynamic-sizing skills, and culture-specific expertise.

U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity-A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S.
This report is a Supplement to the first ever Surgeon General's Report on Mental Health, Mental Health: A Report of the Surgeon General, which provided extensive documentation of the scientific advances illuminating our understanding of mental illness and its treatment. It found a range of effective treatments for most mental disorders. The efficacy of mental health treatment is so well documented that the Surgeon General made this single, explicit recommendation for all people: Seek help if you have a mental health problem or think you have symptoms of a mental disorder. The main findings of this report include that: Mental illnesses are real, disabling conditions affecting all populations, regardless of race or ethnicity; Striking disparities in mental health care are found for racial and ethnic minorities; and Disparities impose a greater disability burden on minorities.

Whaley, A. L. (2003). Ethnicity/race, ethics, and epidemiology. Journal of the National Medical Association, 95(8), 736-742.
Ethnicity/race is a much-studied variable in epidemiology. There has been little consensus about what self-reported ethnicity/race represents but it is a measure of some combination of genetic, socioeconomic and cultural factors. The present article will attempt to: 1.) Elucidate the limitations of contemporary discourse on ethnicity/race that emphasizes the genetic and socioeconomic dimensions as competing explanatory frameworks; 2.) Demonstrate how considerable attention to the cultural dimension facilitates understanding of race differences in health-related outcomes; and 3.) Discuss interpretations of disparities in health status of African Americans versus European Americans from an ethical perspective. A major challenge to the discourse on ethnicity/race and health being limited to socioeconomic and genetic considerations is the lack of attention to the third alternative of a cultural perspective. The combined cultural ideologies of individualism and racism undermine the utility of epidemiological research in health promotion and disease prevention campaigns aimed at reducing the racial gaps in health status. An ethical analysis supplements the cultural perspective. Ethics converge with culture on the notion of values influencing the study of ethnicity/race in epidemiology.

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Guidelines

American Psychological Association (2002). Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists.
Provides six guidelines developed by the American Psychological Association. These guidelines are intended to provide psychologists with 1) the rationale and needs for addressing multiculturalism and diversity in education, training, research, practice, and organizational change, 2) basic information, relevant terminology, current empirical research from psychology and related disciplines, and other data that support the proposed guidelines and underscore their importance, 3) reference to enhance on-going education, training, research, practice, and organizational change methodologies, and 4) paradigms that broaden the purview of psychology as a profession.

Arredondo, P., Toporek, R., Brown, S. P., Sanchez, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). Operationalization of the multicultural counseling competencies. Journal of Multicultural Counseling & Development, 24(1), 42-78.
In 1991-1992, the Professional Standards and Certification Committee of the Association for Multicultural Counseling and Development developed multicultural counseling competencies, and recently provided additional clarification and specified enabling criteria for the revised competencies. Awareness, knowledge, and skills from multicultural perspectives, as defined and described in the competencies, must be part of all counselor preparation and practice. The document is based in large measure on the Dimensions of Personal Identity Model (P. Arredondo and T. Glauner, 1992). This model posits that everyone is a multicultural individual; that everyone possesses a personal, political and historical culture; that everyone is affected by sociocultural, political, environmental, and historical events, and that multiculturalism also intersects with multiple factors of individual diversity.

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Assessing Cultural Competence

Gamst, Glenn, Dana, Richard H., Der-Karabetian, Aghop, Aragon, Myriam, Arellano, Leticia, Morrow, Gloria, Martenson, Luann. (2004). Cultural competency revised: The California Brief Multicultural Competence Scale. Measurement and Evaluation in Counseling and Development, 37, 163-184.
The authors describe the development of the California Brief Multicultural Competence Scale (CBMCS). The 21-item CBMCS was derived from principal component analysis, item content validated by a panel of experts, and confirmatory factor analyses. Several studies provided internal consistency, subscale intercorrelations, criterion-related validation, and assessment of possible social desirability contamination.

Siegel, C., Chambers, E. D., Haugland, G., Bank, R., Aponte, C., McCombs, H. (2000). Performance measures of cultural competency in mental health organizations. Administration and Policy in Mental Health 28(2), 91-106.
The authors utilized numerous documents created by advisory groups, expert panels and multicultural focus groups to develop performance measures for assessing the cultural competency of mental health systems. To provide a national perspective, the focus groups--a total of 134 consumers, family members, advocates and providers--met in locations across the country: New York, Florida, South Carolina, South Dakota, and California. Competency was measured within three levels of organizational structure: administrative, provider network, and individual caregiver. Indicators, measures and data sources for needs assessment, information exchange, services, human resources, plans and policies, and outcomes were identified. Procedures for selection and implementation of the most critical measures are suggested. The products of this project are broadly applicable to the concerns of all cultural groups.

Siegel, C., Haugland, G., Chambers, E.D. (2003). Performance measures and their benchmarks for assessing organizational cultural competency in behavioral health care service delivery. Administration and Policy in Mental Health, 31(2), 141-170.
These benchmarks were developed in response to a concern among consumers of mental health services that the services offered by behavioral healthcare organizations may not be responsive to the special needs of multicultural populations. It describes a two-phase project to recommend and benchmark performance measures that could make these concerns specific and to measure organizational responses. The project focused on the articulated concerns of the four major racial/ethnic groups in the United States: African American, Hispanic American, Asian American, and American Indian.

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Developing Cultural Competence

Alarcón, Renato D., Westermeyer, Joseph, Foulks, Edward F., Ruiz, Pedro. (1999). Clinical relevance of contemporary cultural psychiatry. The Journal of Nervous and Mental Disease, 187(8), 465-471.
In recent years, the field of cultural psychiatry has gained recognition and accumulated evidence of its clinical relevance. This article examines the intersections of culture and psychopathology and describes five independent but interrelated clinical dimensions that identify and define culture as: a) an interpretive/explanatory tool, b) a pathogenic/pathoplastic agent, c) a diagnostic/nosological factor, d) a therapeutic/protective element, and e) a service/management instrument. Along these lines, conceptual boundaries, clinical findings, specific applications, and research implications for each of the five dimensions are systematically reviewed. Cultural psychiatry adds significantly to the comprehensiveness of psychiatric evaluation and management and addresses prominent issues regarding understanding, classification, diagnosis, and competent treatment of most psychiatric disorders in every society and region of the world. Based on the strength of these clinical dimensions, and on the related educational and research efforts, cultural psychiatry can also contribute decisively to the design of comprehensive mental health policies.

Bernal, Guillermo, Sáez-Santiago, Emily. (2006). Culturally centered psychosocial interventions. Journal of Community Psychology, 34 (2), 121-132.
Over the last few decades, psychologists and other health professionals have called attention to the importance of considering cultural and ethnic-minority aspects in any psychosocial interventions. Although, at present, there are published guidelines on the practice of culturally competent psychology, there is still a lack of practical information about how to carry out appropriate interventions with specific populations of different cultural and ethnic backgrounds. In this article, the authors review relevant literature concerning the consideration of cultural issues in psychosocial interventions. They present arguments in favor of culturally centering interventions. In addition, they discuss a culturally sensitive framework that has shown to be effective for working with Latinos and Latinas. This framework may also be applicable to other cultural and ethnic groups.

Comas-Díaz, Lillian. (2006). Cultural variation in the therapeutic relationship. In Evidence- based psychotherapy: Where practice and research meet. Washington, DC: American Psychological Association, 81-105.
The therapeutic alliance is of utmost importance in the multicultural therapeutic relationship. This chapter explores the role of culture within the therapeutic relationship and examines the relevant literature, including that on evidence-based treatment of individuals from other cultures. Moreover, it offers recommendations for addressing the cultural components of the client-therapist relationship to increase psychotherapy's effectiveness. For the purposes of this chapter, the author uses the term culture in a broad sense to include ethnicity, race, gender, age, sexual orientation, social class, physical ability, religion and spirituality, nationality, language, immigration and refugee status, and generational level and the interactions among these characteristics.

Dana, Richard H. (2005). Multicultural assessment: Principles, applications, and examples. Mahwah, NJ: Lawrence Erlbaum Associates, Publishers.
Psychologists throughout the world are being asked to assess an increasingly diverse clientele: immigrants, refugees, second and third generations still influenced by different cultures and languages, and indigenous peoples now moving towards the mainstream. Most are ill-equipped by training and experience to understand, assess, and subsequently treat such clients competently and ethically. Virtually all agree on the need for culture-sensitive assessment, but it has proven difficult to provide adequate services, despite good intentions and funding. Too often, clients who may have different worldview and health-illness beliefs are marginalized. For many reasons, standard assessment instruments designed, researched, and normed on a few groups in the United States--the MMPI-2, the Rorschach, and the TAT--are used as though they were universally applicable. Most busy practitioners have little time to investigate alternatives developed for use with one new group or another, focused on one issue or another, generally in a research context. In this book, the author proposes a new model of multicultural assessment practice and points directions for future training and research. He presents general, culture-specific, and step-by-step instrument-specific guidelines for the use of the standard armamentarium with different groups. Throughout, he highlights exciting new interpretive possibilities the traditional tests offer that should be regularly exploited, but emphasizes the importance of recognizing psychometric limits. Four extended examples of the use of one or several instruments with a specific group offer concrete illustrations of the model in action. Multicultural Assessment: Principles, Applications, and Examples constitutes an invaluable new resource for psychologists and for their students and trainees.

Dana, Richard H. (2002). Mental health services for African Americans: A cultural/racial perspective. Cultural Diversity and Ethnic Minority Psychology, 8(1), 3-18.
African Americans have made consistent progress toward first-class citizenship since 1965. Nonetheless, mental health services for this population have been biased, incomplete, and deficient because similarities to European Americans have been emphasized whereas differences were largely ignored. This article addresses some differences, including cultural/racial identity and the cultural self, that affect assessment, psychiatric diagnoses, and psychotherapy or other interventions. An assessment-intervention model illustrates how cultural information can inform service delivery and improve services to African Americans. Cultural/racial perspectives on mental health in a multicultural society suggest innovations in the design of these services and access to them that can increase utilization by African Americans.

Dana, Richard H. (2001). Clinical diagnosis of multicultural populations in the United States. In Handbook of multicultural assessment: Clinical, psychological, and educational Application. San Francisco, CA: Jossey-Bass, 101-131.
This book discusses the clinical diagnosis of people from diverse cultures. The author discusses the importance of understanding "symptomatology" in a cultural context. He points out that although there have been great strides in bringing a cross-cultural context to nosological systems [such as the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV)], significant bias still exists. A 6-stage model of clinical diagnosis, specifically designed to reduce bias in clinical classification, is outlined.

Dana, Richard H. (2000). The cultural self as locus for assessment and intervention with American Indians/Alaska Natives. Journal of Multicultural Counseling and Development, 28(2), 66-82.
The author compares mental health services from Anglo-American and Native perspectives, focusing on the cultural self as a suggested locus for greater credibility and increased use of these services. Cultural competence is recommended as a model for community-specific policy for the design and implementation of services to increase the probability of generalization to various tribal settings. Cultural competence of Anglo-American providers with this population is discussed.

Friedman, Steven. (2001). Cultural issues in the assessment of anxiety disorders. In Practitioner's guide to empirically based measures of anxiety. Dordrecht, Netherlands: Kluwer Academic Publishers, 37-41.
Notes that mental health professionals are increasingly called on to provide culturally relevant services to diverse groups. In the 21st century, ethnic and cultural groups will continue to travel and intermingle in an unprecedented manner, complicating the task of assessment and treatment for mental health clinicians. Much of the research on developing assessment instruments for anxiety has been performed by North American researchers. Even with empirically validated assessment tools, the assumption has been that anxiety is experienced and communicated to others in similar ways across the world. However, as L. J. Kirmayer (1997) and other cross-cultural researchers have noted, developments in emotion theory highlight the place of culture in the emotional and expressive experience of anxiety. Whereas cross-cultural epidemiological surveys (E. Horwath & M. M. Weissman, 1997; M. M. Weissman et al, 1997) have found very similar rates of anxiety disorders across cultures, there appear to be variations in how anxiety symptoms are described and experienced across the world. This chapter briefly reviews some of the issues that culture and ethnicity pose in the assessment of anxiety, and discusses the implications of these issues for clinical practice in ethnically diverse societies.

Gibbs, Jewelle Taylor, Huang, Larke, Nahme. (2003). Children of color: Psychological interventions with culturally diverse youth. San Francisco, CA: Jossey-Bass.
This book discusses the unique problems and special needs of minority youth experiencing psychological and behavioral problems. This book presents information on culturally sensitive and culturally competent assessment and treatment approached for young African American, Asian American, Central American, Latinos, Native American, biracial-bicultural, and other so-called minority youth. This book contains statistical data, demographics, and intervention techniques, contributed by ethnically diverse mental health professionals..

Hernandez, Mario, (Ed), Isaacs, Mareasa R., (Ed). (2003). Promoting cultural competence in children's mental health services. Baltimore, MD: Paul H. Brookes Publishing.
This volume offers ways to improve children's mental health programs in a multicultural society. It defines cultural competence and outlines strategies for fostering it in a wide variety of mental health programs for children from birth to age 18 and their families. Mental health administrators and service providers will find self-assessment tools, troubleshooting suggestions, planning assistance, methods for recruiting and retaining ethnically diverse staff, and tips on operating in a managed care environment. The book is intended as a reference for social workers, counselors, psychiatrists, school psychologists, public health officials, and health care professionals.

LaFromboise, Teresa D., Trimble, Joseph E., & Mohatt, Gerald V. (1998). Counseling intervention and American Indian tradition: An integrative approach. In Counseling American minorities (5th ed.). New York, NY: McGraw-Hill, 159-182.
This chapter outlines the process of helping from an American Indian traditional healing perspective and describes beliefs associated with efforts toward maintaining wellness and overcoming psychological disturbance. Studies addressing social influence variables that contribute to cultural clashes associated with individual and group counseling are reviewed along with research that supports the efficacy of selected counseling interventions with Indian clients. Considerations for the employment of culturally unique and conventional psychological interventions to advance the goal of Indian empowerment are enumerated. Tribal diversity and structural similarities are suggested in case material illustrating typical case presentations found in service delivery settings with American Indians. Finally, future directions in counseling and research training to prepare counseling psychologists to integrate conventional counseling interventions with American Indian tradition are provided.

Lee, Lee C., (Ed), Zane, Nolan W. S., (Ed). (1998). Handbook of Asian American psychology. Thousand Oaks, CA: Sage Publications, Inc.
This book provides a reference on topics that are germane to the understanding of Asian Americans. This handbook provides insights into the diverse and varied nature of Asian American cultures. It will be of use to professionals, students, and academics in ethnic studies, psychology, social welfare, gender studies, family studies, nursing, gerontology, research methods, and interpersonal communication. (Taken from the preface) This volume integrates descriptions and evaluations of psychological research on all ethnic subgroups of Asian Americans. It begins with an overview of Asian America to provide a historical and contemporary context of U.S. societal treatment of Asians. It provides a basis for understanding the research findings presented in the subsequent chapters. Finally, it provides insight into the diverse and varied nature of Asian American cultures and communities.

Leong, Frederick T. L., & Lau, Anna S. L. (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3(4), 201-214.
Using the research framework recommended by L. Rogler, R. Malgady, and D. Rodriguez (1989), the current paper examines the barriers to providing effective mental health services to Asian Americans. Beginning with the recognition that Asian Americans consists of numerous heterogeneous subgroups, the issue of the stereotype of Asian Americans as the “model minority” was also discussed. The primary focus of the paper is on Stages 2, 3, and 4 within the Rogler et al. (1989) model and the identification and discussion of cultural factors that hinder the delivery of mental health services to Asian Americans. The paper is therefore organized into these three sections: (a) help-seeking or mental health service utilization, (b) evaluation of mental health problems, and (c) psychotherapeutic services. In each of the sections, not only are the barriers to delivery of effective mental health services discussed but so are the research and methodological problems as well as some directions for future research. This critical review of the literature has been prepared with the goal of serving as a “blueprint” for us to pursue rigorous but relevant research to identify and reduce these cultural barriers to providing effective mental health services to Asian Americans.

Lopez, S. R. (1997). Cultural competence in psychotherapy: A guide for clinicians and their supervisors. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 570-588). New York, NY: John Wiley & Sons.
The purpose of this chapter is to outline a model of culturally competent psychotherapy that can be used to guide both supervisors and trainees in their clinical work with culturally diverse clients. In an effort to study the empirical basis of cultural competence, it begins by examining practitioners' clinical judgment, particularly their judgment of clients' presenting problems and symptomatology. Based on qualtitative observations of clinical trainees, it then extends to psychotherapy. More recently, it applies these ideas to formal psychological assessment. This chapter critically reviews this line of research and the model of cultural competence that it suggests. Next, it addresses the model's limitations and then presents a revised model of cultural competence and illustrates the model with clinical cases. Although the model of cultural competence is likely to be applicable to the treatment of clients from all ethnocultural groups, it may be most applicable to the treatment of ethnocultural minority groups.

Lopez, S. R., Grover, K. P., Holland, D., Johnson, M. J., Kain, C. D., Kanel, K., Mellins, C. A., & Rhyne, M. C. (1989). Development of culturally sensitive psychotherapists. Professional Psychology: Research and Practice, 20(6), 369-376.
Proposes a developmental model to describe how student-therapists learn to appropriately consider cultural factors in their clinical work with culturally diverse clients. The model is derived from discussions held in a seminar concerning mental health services and culture and from students' written accounts of how they considered cultural factors in providing therapy. Vignettes based on the written accounts are presented to illustrate the key developmental processes hypothesized to underlie psychotherapists' growing cultural sensitivity. The proposed model is contrasted with past models of therapist development. A research agenda guided by a social cognitive perspective is offered to test the proposed model.

Lu, Francis G., Primm, Annelle. (2006). Mental health disparities, diversity, and cultural competence in medical student education: How psychiatry can play a role. Academic Psychiatry, 30(1), 9-15.
The authors review recent developments in healthcare policy, including eliminating disparities in mental healthcare, increasing diversity in the healthcare workforce, and cultural competence. Following a discussion of the Liaison Committee on Medical Education (LCME) standards, as they relate to disparity, cultural competence, and diversity, the authors discuss an action plan describing the role of psychiatry in addressing these issues. Methods: Key policy documents are reviewed for disparities, cultural competence, and diversity in healthcare and then in mental health specifically. Results: Important developments in healthcare policy regarding these areas have occurred. Conclusion: Psychiatry can play a vital role in addressing disparities, cultural competence, and diversity in medical student education.

Ridley, Charles R. (2005).Overcoming unintentional racism in counseling and therapy: A practitioner's guide to intentional intervention. In Multicultural aspects of counseling and psychotherapy series. Thousand Oaks, CA: Sage Publications, Inc.
Any counselor or therapist, regardless of race, background, or motive, can engage in unintentional acts of racism. In so doing, they may inadvertently sabotage their own efforts and perpetuate the very problems they seek to overcome. Overcoming Unintentional Racism in Counseling and Therapy, Second Edition examines the dynamics and effects of racism in counseling with an emphasis on the insidiousness of unintentional racism. Workable solutions and practical alternatives are proposed with numerous supporting clinical examples included to help counselors and psychotherapists gain new insights into their operational practices, and modify any behaviors that may interfere with a helpful intervention. The Second Edition also provides a new section on the policies and practices of agencies and other institutions in the mental health system that unintentionally results in service disparities. Macrosystem and micro-system interventions are proposed to overcome these disparities. Key features of this text include: discussion on unintentional racism in counseling and therapy; balance of theory and practice; problem identification and solutions. The text is suited as a supplemental text for theoretical courses in counseling, counseling techniques, practicum, multicultural counseling, and in professional seminars.

Ridley, Charles R., Li, Lisa C. and Hill, Carrie L. (1998). Multicultural assessment: Reexamination, reconceptualization, and practical application. The Counseling Psychologist, 26(6), 827.
Current suggestions for assessing clients across cultures fail to adequately aid the average practitioner. This failure arises from unresolved issues and problems, interfering with the ability of most counselors and therapists to render sound clinical judgments. In response to these issues and problems, a procedure is described that sensitizes counselors to cultural data in assessment and case conceptualization. Grounded in a guiding philosophy of assessment, the Multicultural Assessment Procedure (MAP) was developed in consideration of a number of relevant critical issues. The procedure entails identifying cultural data through multiple methods of data collection, interpreting cultural data to formulate a working hypothesis, incorporating cultural data with other relevant clinical information to test the working hypothesis, and arriving at a sound (i. e., comprehensive and accurate) assessment decision. A case illustration demonstrates how to use the proposed procedure.

Ridley, Charles R., Lingle, Danielle W. (1996). Cultural empathy in multicultural counseling: A multidimensional process model. In Counseling across cultures (4th ed.). Thousand Oaks, CA: Sage Publications, Inc., 21-46.
This article reformulates and develops the concept of cultural empathy in multicultural counseling and summarizes the major issues in the traditional empathy literature. The authors also review critically the use of empathy in the multicultural literature and propose a [multidimensional process] model of cultural empathy. The article also shows how the construct may be applied in practice.

Rogler, Lloyd H., Malgady, Robert G., Costantino, Giuseppe, Blumenthal, Rena. (1998). What do culturally sensitive mental health services mean? The case of Hispanics. In Counseling American minorities (5th ed.). New York, NY: McGraw-Hill, 268-279.
What do culturally sensitive mental health services mean? To answer this question, the authors examined the use of the concept by mental health practitioners and researchers in their work with Hispanics. In doing so, the authors uncovered 3 broad approaches to cultural sensitivity: first, rendering traditional treatments more accessible to Hispanics; second, selecting an available therapeutic modality according to the perceived features of Hispanic culture; and third, extracting elements from Hispanic culture and using them to modify traditional treatments or as an innovative treatment tool.The first purpose of this chapter is to describe the components of cultural sensitivity within each of the three approaches mentioned above. The second purpose is to examine the relationship between culture and therapy in the literature on Hispanics by posing a fundamental question: Must the content of all culturally sensitive therapies stand in an isomorphic, mirror-like relationship to the client's culture? Inferences drawn from the literature and the authors' own research justify raising this question.

Snowden, Lonnie R. (2001). Barriers to effective mental health services for African Americans. Mental Health Services Research, 3(4), 181-187.
Many African Americans—especially the most marginal—suffer from mental health problems and would benefit from timely access to appropriate forms of care. However, few seek treatment from outpatient providers in the specialty mental health sector and those who do are at risk of dropping out. African Americans visit providers in the general medical sector, although they use another hypothesized alternative to specialty care, voluntary support networks, less than other groups. These help-seeking tendencies may reflect characteristic coping styles and stigma, as well as a lack of resources and opportunities for treatment. More should be learned about differences in need according to location, social standing, and cultural orientation so as to identify treatments and programs that are especially beneficial to African Americans.

Sue, Stanley. (2006). Cultural competency: From philosophy to research. Journal of Community Psychology, 34(2), 237-245.
Cultural competency in the delivery of mental health services has gained considerable momentum. This momentum has been accompanied by questions about the meaning, usefulness, and precision of cultural competency. The author argues that cultural competency is composed of general processes (scientific mindedness, dynamic sizing, and culture-specific skills), as well as a series of concrete and trainable strategies. The incorporation of these processes and strategies into treatment can improve treatment outcomes with clients from diverse cultural backgrounds.

Sue, Stanley, Chu, June Y. (2003). The mental health of ethnic minority groups: Challenges posed by the supplement to the Surgeon General’s Report on Mental Health. Culture, Medicine and Psychiatry, 27, 447-265.
In contrast to the conclusions reached by the Supplement to the Surgeon General’s report on mental health, there is evidence that the various ethnic minority groups may exhibit significant differences in the prevalence of mental disorder. These differences cannot be fully explained by disparities or inequities in mental health services. African Americans appear to have relatively low prevalence rates despite a history of prejudice, discrimination, and the resulting stress. Ethnic differences are also revealed by findings that acculturation is negatively related to mental health for Mexican Americans and positively related to mental health for Asian Americans. Implications of these findings are discussed.

Trimble, Joseph E. (2003). Cultural sensitivity and cultural competence. In The portable mentor: Expert guide to a successful career in psychology. New York, NY: Kluwer Academic/Plenum Publishers, 13-32.
The intent of this chapter is to provide a framework for achieving and maintaining cultural competence and cultural sensitivity. To achieve the goal, the chapter is organized along several points where cultural competence and sensitivity are salient and prerequisites for conducting research and providing psychological services. Definitions and guidelines are provided for the two constructs followed by a brief discussion of the terms, ethnicity, ethnic group, and culture. Suggestions are provided for achieving competence as a counselor, clinician, researcher, and at a personal level. Since the achievement of cultural competence and sensitivity requires common skills and psychological perspectives, emphasis will be placed on the research setting. Thus, the chapter's last section focuses on cross-cultural methodological and procedural concerns including gaining entry to the field, cultural measurement equivalence, and collecting data and reporting the findings.

Trimble, Joseph E., Fleming, Candace M., Beauvais, Fred, Jumper-Thurman, Pamela. (1996). Essential cultural and social strategies for counseling Native American Indians. In Counseling across cultures (4th ed.). Thousand Oaks, CA: Sage Publications, Inc., 177-209.
The purpose of this chapter is to identify and describe the essential ingredients that will lead to effective counseling strategies for Native American Indian clients and provide a sociodemographic description of Native American Indian populations. The author also defines those cultural elements that distinguish Native American Indian populations and that relate to the dimensions of the counseling process and describes counselor characteristics that have been shown to provide the best match for counseling with American Indians.

Westermeyer, Joseph, Janca, Aleksandar.(1997). Language, culture and psychopathology: Conceptual and methodological issues. Transcultural Psychiatry, 34(3), 291-311.
The World Health Organization has developed scheduled interviews to make psychiatric diagnoses that are comparable across languages and cultures. Work on these interview schedules in numerous languages has demonstrated the importance of lay terminology in eliciting the presence of psychiatric symptoms and assessing their severity. Lay terminology regarding subjective experiences and perceptions is strongly tied, through language, to cultural values, attitudes, norms, beliefs, and customs. The authors outline critical concepts and methods regarding psychopathology, language, and culture. General concepts defined and discussed include denotation, connotation, various types of equivalence in translated materials, specificity of terms, and reporting threshold in relation to symptom severity. Methods for ensuring equivalence of words, items, and instruments across languages and cultures are presented. Other assessment topics related to culture and psychiatry include confidentiality, choice of a language for assessing multilingual patients, methods of eliciting certain psychological experiences, culturally taboo topics, and cultural nuances regarding mental status examination.

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Evidence-Based Practices (EBPs)

Rationale & Overviews

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7-18.
A scheme is proposed for determining when a psychological treatment for a specific problem or disorder may be considered to be established in efficacy or to be possibly efficacious. The importance of independent replication before a treatment is established in efficacy is emphasized, and a number of factors are elaborated that should be weighed in evaluating whether studies supporting a treatment's efficacy are sound. It is suggested that, in evaluating the benefits of a given treatment, the greatest weight should be given to efficacy trials but that these trials should be followed by research on effectiveness in clinical settings and with various populations and by cost-effectiveness research.

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.
Efforts to increase the practice of evidence-based psychotherapy in the US have led to the formation of task forces to define, identify, and disseminate information about empirically supported psychological interventions. The work of several such task forces and other groups reviewing empirically supported treatments (ESTs) in the US, UK, and elsewhere is summarized here, along with the lists of treatments that have been identified as ESTs. Also reviewed is the controversy surrounding EST identification and dissemination, including concerns about research methodology, external validity, and utility of EST research, as well as the reliability and transparency of the EST review process.

Chorpita, B. F. (2003). The frontier of evidence-based practice. In A. E. Kazdin and J. R. Weisz (Eds.) Evidence-based psychotherapies for children and adolescents (pp. 42-59). New York: Oxford.
This chapter discusses the frontier of evidence-based practice. Many of the recent developments regarding evidence-based practice stemmed from the work by the Task Force on Psychological Intervention Guidelines of the American Psychological Association. These guidelines emphasized the dimensions of 1) efficacy and 2) effectiveness. A model is provided that proposes how evidence--however defined--will ultimately connect with practice. This chapter suggests that many of the problems stem from the nature of the outcome research and the resulting definition of evidence. The author contends that it is important to consider some different types of research and their implications for system engagement.

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Jensen, P. S., Weersing, R., Hoagwood, K. E., & Goldman, E. (2005). What is the evidence for evidence-based treatments? A hard look at our soft underbelly? Mental Health Services, 7, 53-74.
In the rising quest for evidence-based interventions, recent research often does not give adequate attention to nonspecific therapeutic factors, including the effects of attention, positive regard, and therapeutic alliance, as well as the effects of treatment dose, intensity and actual processes mediating therapeutic change. To determine the extent to which recent clinical trial designs fully this problem, the authors conducted a systematic review of PsychLit/Medline of all controlled child psychotherapy treatment studies from 1995 to 2004. A total of 52 studies were identified that met review criteria: two or more therapy conditions and random assignment of participants to intervention groups. When positive effects were found, few studies systematically explored whether the presumed active therapeutic ingredients actually accounted for the degree of change, nor did they often address plausible alternative explanations, such as nonspecific therapeutic factors of positive expectancies, therapeutic alliance, or attention. Findings suggest that many child psychotherapy treatment studies have not inadequately controlled for nonspecific factors such as attention and treatment intensity and have failed to assess specific mediators of change. Specific recommendations for future studies are offered.

Messer, S. B. (2004). Evidence-based practice: Beyond empirically supported treatments. Professional Psychology: Research and Practice, 35(6), 580-588.
Must the clinician choose between a practice that is strictly objective and data based and one that is purely subjective and experience based? Optimally, practitioners need to follow a model of evidence-based psychotherapy practice, such as the disciplined inquiry or local clinical scientist model, that encompasses a theoretical formulation, empirically supported treatments (ESTs), empirically supported therapy relationships, clinicians' accumulated practical experience, and their clinical judgment about the case at hand. Some shortcomings of ESTs are reviewed, and a form of evidence for psychotherapy practice is presented that entails the accumulation of systematic case studies published online. Practitioners can contribute to such a database and be guided in their practice by those cases most relevant to their clients' problems.

O'Donohue, W., Buchanan, J. A., & E., F. J. (2000). Characteristics of empirically supported treatments. Journal of Psychotherapy Practice Research, 9(2), 69-74.
Presents a survey of general characteristics of empirically supported psychotherapeutic treatments (ESTs) identified by the American Psychological Association (APA) Division 12 Task Force (APADTF) on the Promotion and Dissemination of Psychological Procedures. Participants were authors of studies cited as supporting the inclusion of the treatment as a "well-established" EST or a "probable" EST in the APADTF reports on empirically supported treatments. An 11-item questionnaire designed to assess various characteristics of ESTs was mailed to each S. The authors' goal was to obtain 1 completed questionnaire for each full and probable EST. Results show that the ESTs share the following characteristics: they involve skill building, have a specific problem focus, incorporate continuous assessment of client progress, and involve brief treatment contact, requiring 20 or fewer sessions. Traditional assessment methods, such as intelligence testing, projectives, and objective personality tests such as the MMPI-2, are rarely used in these treatments. Although it is recognized that these findings are in part an artifact of sociological factors present in contemporary psychotherapy development and research, the findings may also serve as a heuristic aid in the development of therapies.

Sackett, D.L., Rosenberg, W.M.C, Gray, J.A.M., Haynes, R.B., & Richardson, W.S. (1996). Evidence-based medicine: What it is and what it isn't. British Medical Journal, 312, 71-72.
Evidence based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, remains a hot topic for clinicians, public health practitioners, purchasers, planners, and the public. There are now frequent workshops in how to practice and teach it (one sponsored by the BMJ will be held in London on 24 April); undergraduate and postgraduate training programs are incorporating it (or pondering how to do so); British centers for evidence based practice have been established or planned in adult medicine, child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane Collaboration and Britain's Centre for Review and Dissemination in York are providing systematic reviews of the effects of health care; new evidence based practice journals are being launched; and it has become a common topic in the lay media. But enthusiasm has been mixed with some negative reaction. Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom. As evidence based medicine continues to evolve and adapt, now is a useful time to refine the discussion of what it is and what it is not.

Tanenbaum, S. J. (2005). Evidence-based practice as mental health policy: Three controversies and a caveat. Health Affairs, 24(1), 163-173.
Evidence-based practice (EBP) is the subject of vigorous controversy in the field of mental health. In this paper I discuss three distinct but interrelated controversies: how inclusive the mental health evidence base should be; whether mental health practice is a variety of applied science; and when and how the effectiveness goal in mental health is defined. I provide examples of evidence-based policy in mental health. These controversies pertain as well to general medicine. To the extent that they remain unresolved, evidence-based policy making may lead to ineffective and limited care.

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Guidelines

DeRubeis, R.J., & Crits-Christoph, P. (1998). Empirically supported individual and group psychological treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66(1), 37-52.
The experimental literature on individual and group psychological treatments for adult disorders is reviewed. For each of the 11 disorders or problems covered, treatments that fall into the following categories, as defined by D. L. Chambless and S. D. Hollon (1998), are identified: efficacious and specific, efficacious, and possibly efficacious. Behavioral and cognitive-behavioral treatments dominate the lists, especially in the anxiety disorders, with notable exceptions. Reasons for the hegemony of the behavioral and cognitive modalities are discussed, and some limitations of the empirically supported treatment concept are addressed. Continued Treatment interactions, cost-benefit _ research is recommended on Aptitude ratios, and generalization of treatments to a variety of patient populations, therapists, and treatment settings.

Hawaii Department of Health. (2004). Summary of effective interventions for youth with behavioral and emotional needs. Evidence Based Services Committee Biennial Report.
This report summarizes recent findings related to effective interventions for youth with behavioral and emotional needs. The goal of this report is to broaden and update the summary of scientific information used to guide decisions about children's care. The three major sections of the report are 1) a composite of the major randomized, controlled research findings, with attention to promising outcomes, provider type, intervention setting, nature of the children, and a host of other factors, 2) a summary of the evidence on medication efficacy and safety, based on published reviews and supplemental reports, and 3) consensus summaries specific to nominated topics regarding practice policy for which no limited or no controlled research was available.

Hoagwood, K., Burns, B.J., Kiser, L., Ringeisen, H., & Schoenwald, S.K. (2001). Evidence-based practice in child and adolescent mental health services. Psychiatric Services, 52(9), 1179-1189.
The authors review the status, strength, and quality of evidence-based practice in child and adolescent mental health services. The definitional criteria that have been applied to the evidence base differ considerably across treatments, and these definitions circumscribe the range, depth, and extensionality of the evidence. The authors describe major dimensions that differentiate evidence-based practices for children from those for adults and summarize the status of the scientific literature on a range of service practices. The readiness of the child and adolescent evidence base for large-scale dissemination should be viewed with healthy skepticism until studies of the fit between empirically based treatments and the context of service delivery have been undertaken. Acceleration of the pace at which evidence-based practices can be more readily disseminated will require new models of development of clinical services that consider the practice setting in which the service is ultimately to be delivered.

Virginia Commission on Youth. (2003). Collection of evidence-based treatment modalities for children and adolescents with mental health treatment needs. House Document No. 9.
This reference chart provides detailed information on evidenced-based children's mental health. For each disorder/behavior, the chart identifies support for treatment, positive effects/consistent evidence, inconsistent evidence/unproven, and comments.

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Implementation Issues

Carpinello SE, Rosenberg L, Stone J, Schwager M, and Felton CJ (2002). Best practices: New York state's campaign to implement evidence-based practices for people with serious mental disorders. Psychiatric Services, 53(2), 153-5.
This article provides information related to a campaign in New York that strived to implement evidence-based practices for mental illness. The article reviews the core set of evidence-based practices, the changing environment and challenges in the mental health field, and conclusions related to implementation of evidence-based practices.

Chorpita, B. F., & Nakamura, B. J. (2004). Four considerations for dissemination of intervention innovations. Clinical Psychology: Science and Practice, 11, 364-367.
The current paper offers four considerations related to Stirman, Crits-Cristoph, and DeReubis' (this issue) (see record 2004-20381-001) insightful review on general theories relevant to the dissemination of psychological interventions and major obstacles associated with the dissemination effort. Readers are asked to consider (a) the notion that the dissemination of a psychological intervention is not equivalent to unidirectional product delivery, (b) the importance of examining local uncontrolled evidence alongside controlled research evidence, (c) design strategies to facilitate adapting evidence-based interventions for community settings, and (d) fostering working partnerships between laboratories and the communities.

Drake, R.E., Goldman, H.H., Leff, H.S., Lehman, A.F., Dixon, L., Mueser, K.T., & Torrey, W.C. (2001). Implementing evidence-based practices in routine mental health service settings. Psychiatric Services, 52(2), 179-82.
The authors describe the rationale for implementing evidence-based practices in routine mental health service settings. Evidence-based practices are interventions for which there is scientific evidence consistently showing that they improve client outcomes. Despite extensive evidence and agreement on effective mental health practices for persons with severe mental illness, research shows that routine mental health programs do not provide evidence-based practices to the great majority of their clients with these illnesses. The authors define the differences between evidence-based practices and related concepts, such as guidelines and algorithms. They discuss common concerns about the use of evidence-based practices, such as whether ethical values have a role in shaping such practices and how to deal with clinical situations for which no scientific evidence exists.

Goldman, H.H., Ganju, V., Drake, R.E., et al. (2001). Policy implications for implementing evidence-based practices, Psychiatric Services, 52(12), 1591-1597.
The authors describe the policy and administrative-practice implications of implementing evidence-based services, particularly in public-sector settings. They review the observations of the contributors to the evidence-based practices series published throughout 2001 in Psychiatric Services. Quality and accountability have become the watchwords of health and mental health services; evidence-based practices are a means to both ends. If the objective of accountable, high-quality services is to be achieved by implementing evidence-based practices, the right incentives must be put in place, and systemic barriers must be overcome. The authors use the framework from the U.S. Surgeon General's 1999 report on mental health to describe eight courses of action for addressing the gap between science and practice: continue to build the science base; overcome stigma; improve public awareness of effective treatments; ensure the supply of mental health services and providers; ensure delivery of state-of-the-art treatments; tailor treatment to age, sex, race, and culture; facilitate entry into treatment; and reduce financial barriers to treatment.

Schoenwald, S.K., & Hoagwood, K. (2001). Effectiveness, transportability and dissemination of interventions: What matters when? Psychiatric Services, 52, 1190-1197.
The authors identify and define key aspects of the progression from research on the efficacy of a new intervention to its dissemination. They highlight the role of transportability questions that arise in that progression and illustrate key conceptual and design features that differentiate efficacy, effectiveness, and dissemination research. An ongoing study of the transportability of multisystemic therapy is used to illustrate independent and interdependent aspects of effectiveness, transportability, and dissemination studies. Variables relevant to the progression from treatment efficacy to dissemination include features of the intervention itself as well as variables pertaining to the practitioner, client, model of service delivery, organization, and service system. The authors provide examples of how some of these variables are relevant to the transportability of different types of interventions. They also discuss sample research questions, study designs, and challenges to be anticipated in the arena of transportability research.

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Specific EBPs

Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31.
This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.

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EBPs and Populations of Color

Overviews

Bernal, G., & Scharron-del-Rio, M. R. (2001). Are empirically supported treatments valid for ethnic minorities? Toward an alternative approach for treatment research. Cultural Diversity and Ethnic Minority Psychology, 7(4), 328-342.
The psychological community has given considerable attention to the problem of establishing empirically supported treatments (ESTs). The authors argue that a scientific practice that discriminates against some approaches to knowledge undermines the EST's relevance for communities of color. They examine the EST project's contribution to knowledge of effective treatments for ethnic minorities by considering both how knowledge is constructed and the limits of research (e.g., external validity). Alternatives on how to best contribute to treatment research of clinical utility with diverse populations are articulated. An approach for treatment research, derived from an integration of the hypothesis-testing and discovery-oriented research approaches, is presented, and recommendations to advance treatment research with ethnic minority communities are offered.

Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, W.-C., & LaFromboise, T. (2005). State of the science on psychosocial interventions for ethnic minorities. Annual Review of Clinical Psychology, 1, 113-142.
Presents a review of the research literature on the impact of evidence-based mental health care on ethnic minorities. We found a growing literature that supports the effectiveness of this care for ethnic minorities. The largest and most rigorous literature available clearly demonstrates that evidence-based care for depression improves outcomes for African Americans and Latinos, and that results are equal to or greater than for white Americans. Much fewer data are available for Asian populations, but the literature that is available suggests that established psychosocial care may well be effective for this population. The available literature focuses on preventive interventions for youths. These studies show us that Native populations engage in school-based interventions that do not target particular youths, but rather provide interventions for all. We believe that the existent literature suggests that evidence-based parent management training and attention deficit disorder with hyperactivity care for children and depression treatments for adults do generalize to African American and Latino populations. In fact, the literature to date would suggest that evidence-based care is likely to generalize to both African American and Latino populations. Although the evidence is very sparse for Asian Americans, initial studies appear positive.

Miranda, J., Nakamura, R., & Bernal, G. (2003). Including ethnic minorities in mental health intervention research: A practical approach to a long-standing problem. Culture, Medicine and Psychiatry, 27, 467-486.
This paper examines a controversy that arose while developing a supplement to Mental Health: A Report of the Surgeon General that was focused on ethnic minority mental health. The controversy involved whether and how to make recommendations about ethnic minorities seeking mental health care. We found that few studies provided information on outcomes of mental health care for ethnic minorities. In this paper, we discuss outcomes of mental health care for ethnic minorities and how to proceed in developing an evidence base for understanding mental health care and minorities. We conclude that entering representative (based on population) numbers of ethnic minorities in efficacy trials is unlikely to produce useful information on outcomes of care because the numbers will be too small to produce reliable findings. We also conclude that while conducting randomized efficacy trials for all mental health interventions for each ethnic group would be impractical, innovative and theoretically informed studies that focus on specific cultural groups are needed to advance the knowledge base. We call for theory-driven research focused on mental health disparities that has the potential for understanding disparities and improving outcomes for ethnic minority populations.

Nagayama Hall, G. C. (2001). Psychotherapy research with ethnic minorities: Empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology, 69(3), 502-510.
There is an increasing demand for psychotherapy among ethnic minority populations. Yet, there is not adequate evidence that empirically supported therapies (ESTs) are effective with ethnic minorities. Ethical guidelines suggest that psychotherapies be modified to become culturally appropriate for ethnic minority persons. Conceptual approaches have identified interdependence, spirituality, and discrimination as considerations for culturally sensitive therapy (CST). However, there is no more empirical support for the efficacy of CSTs than there is for the efficacy of ESTs with ethnic minority populations. The chasm between EST and CST research is a function of differences between methods and researchers in these 2 traditions. Specific recommendations for research collaboration between CST and EST researchers are offered.

National Implementation Research Network. (2003). Consensus statement on evidence-based programs and cultural competence.
This consensus statement was developed in March 2003 through a meeting of experts in the area of children's mental health and cultural competence. It was convened by the National Implementation Research Network of the Louis de la Parte Florida Mental Health Institute in conjunction with the Annie E. Casey Foundation. The goals of the meeting were to 1) address the applicability and appropriateness of evidence-based programs for children and adolescents of different cultures and 2) increase the capacity of systems to develop and implement relevant approaches. The consensus statement consists of what we know and what we do not know about the relationship between evidence-based programs and cultural competence. It provides both a platform and a guide for discussions and decisions related to the cultural relevance of evidence-based programs for children and adolescents, as well as recommendations for future actions, based on participant knowledge and experience.

Siegel, Carole, Haugland, Gary, Schore, Robert. (2005). The interface of cultural competency and evidence-based practices. In Evidence-based mental health practice: A textbook. New York, NY: W. W. Norton & Co., 273-299.
This chapter argues one method for incorporating cultural diversity to improve treatment is through the implementation of evidence-based practices (EBPs). In the national EBP project, CC has been taken into consideration in the promotion of these services. All stakeholder groups have reviewed the EBP toolkits for how language applies to culture and to determine whether the vignettes used reflect cultural diversity. Scientific evidence, however, is limited for cultures other than the major culture. This dearth of evidence raises several questions that will need to be answered as EBPs are implemented nationwide. Can an EBP that has not been tested on a cultural group be considered an EBP for that group? Or, if the EBP is tailored to the culture by an organization, can the adapted EBP still be considered a scientifically supported EBP? How is the fidelity measurement impacted by cultural applications? This chapter discusses several of these issues. First, we describe the service problems of minority cultures and efforts that have been made to improve service delivery. We then describe the construct of CC and tools for its measurement. Lastly, we discuss the salient role of CC in the adaptation and implementation of EBPs when an agency provides mental health treatment services to people from diverse cultures.

Sue, Stanley, Zane, Nolan. (2006). How well do both evidence-based practices and treatment as usual satisfactorily address the various dimensions of diversity? In Evidence-based practices in mental health: Debate and dialogue on the fundamental question. Washington, D.C: American Psychological Association, 329-374.
In this position paper, we examine the extent to which evidence-based practices (EBPs) have been helpful in reducing disparities and in improving treatment effectiveness. In many ways, we do not have the luxury of debating controversies identified by others (Beutler, 2004; Levant, 2004), such as whether research priority should be directed to treatment or context, whether external validity should be sacrificed for internal validity, or whether efficacy or effectiveness research is more valuable. Rather, we need to emphasize that more ethnic research must be conducted. From the outset, our position is that psychological treatment should be guided by research evidence. However, we believe that EBPs have not been very helpful in reducing treatment disparities or improving effectiveness for minorities, primarily for three reasons. First, little research has been conducted on EBPs with clients from ethnic minority groups. Second, a need exists to broaden the current definition of "evidence." Third, research that tests if existing interventions are effective is limiting. Research into culturally competent interventions is needed, and this kind of research is relatively new. Consequently, the conclusions regarding mental health disparities reached by the President's Commission on Mental Health in 1978 have not changed a quarter of a century later ((President's New Freedom Commission, 2003; U.S. Surgeon General, 2001).

Wong, Eunice C., Kim, Bryan S.K., Zane, Nolan W.S., Kim, Irene J., Huang, John S. (2003). Examining culturally biased variables associated with ethnicity: influences on credibility perceptions of empirically supported interventions. Cultural Diversity and Ethnic Minority Psychology, 9(1), 88-96.
Treatment rationales for 2 widely used and empirically supported interventions, cognitive therapy (CT) and time-limited dynamic psychotherapy (TLDP), were examined for their perceived credibility among 136 Asian American college students. This study conducted a comprehensive analysis of culturally based variables (often assumed to underlie ethnicity) and their related effects on credibility perceptions. Variables assessed included cultural identity, self construals, values, and mental health beliefs. Participants were randomly assigned to read either a CT or TLDP treatment rationale for depression and then rated the credibility of the interventions. Results indicated that cultural identity and self-construals moderated credibility ratings across CT and TLDP rationales. Findings underscore the importance of moving beyond ethnic group analyses to the examination of specific culturally based variables.

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Cultural Adaptations

Barrera, M., & Castro, F.G. (2006). A Heuristic Framework for the Cultural Adaptation of Interventions. Clinical Psychology: Science and Practice, 13(4), 311-316.
What conditions justify cultural adaptations to evidence-based treatments, and how might those adaptations be developed? Lau's (2006) analysis brought considerable clarity to these questions. We place Lau's insights and those of others within an elaborated framework that proposes tests of three types of cultural equivalence to determine when evidence-based treatments might merit adaptations: equivalence of (a) engagement, (b) action theory, and (c) conceptual theory. Extrapolating from Lau's examples and recommendations of others, we describe a sequence for developing adaptations that consists of the following phases: (a) information gathering, (b) preliminary adaptation design, (c) preliminary adaptation tests, and (d) adaptation refinement.

Bernal, Guillermo. (2006). Intervention development and cultural adaptation research with diverse families. Family Process, 45(2), 143-151.
This article provides an introduction to the special issue on intervention development and cultural adaptation research with diverse families. The need for research on intervention development and on cultural adaptation of interventions is presented, followed by a discussion of frameworks on treatment development. Seven articles included in this special issue serve as examples of the stages of treatment and intervention development, and of the procedures employed in the cultural adaptation with diverse families. An overview of the seven articles is provided to illustrate the treatment development process and the use of pluralistic research methods. We conclude with a call to the field for creative and innovative intervention development research with diverse families to contribute to the body of evidence-based practice with these populations.

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.
This article has two objectives. The first is to provide a culturally sensitive perspective to treatment outcome research as a resource to augment the ecological validity of treatment research. The relationships between external validity, ecological validity, and culturally sensitive research are reviewed. The second objective is to present a preliminary framework for culturally sensitive interventions that strengthen ecological validity for treatment outcome research. The framework, consisting of eight dimensions of treatment interventions (language, persons, metaphors, content, concepts, goals, methods, and context) can serve as a guide for developing culturally sensitive treatments and adapting existing psychosocial treatments to specific ethnic minority groups. Examples of culturally sensitive elements for each dimension of the intervention are offered. Although the focus of the article is on Hispanic populations, the framework may be valuable to other ethic and minority groups.

Castro, F.G., Barrera, M., & Martinez, C.R. (2004). The Cultural Adaptation of Prevention Interventions: Resolving Tensions Between Fidelity and Fit. Prevention Science, 5(1), 41-45.
A dynamic tension has developed in prevention science regarding two imperatives: (a) fidelity of implementation-the delivery of a manualized prevention intervention program as prescribed by the program developer, and (b) program adaptation-the modification of program content to accommodate the needs of a specific consumer group. This paper examines this complex programmatic issue from a community-based participatory research approach for program adaptation that emphasizes motivating community participation to enhance program outcomes. Several issues, key concepts, and implementation strategies are presented under a strategic approach to address issues of fidelity and adaptation. Despite the noted tension between fidelity and adaptation, both are essential elements of prevention intervention program design and they are best addressed by a planned, organized, and systematic approach. Towards this aim, an innovative program design strategy is to develop hybrid prevention programs that "build in" adaptation to enhance program fit while also maximizing fidelity of implementation and program effectiveness.

Coard, S.I., Wallace, S.A., Stevenson, H.C., & Brotman, L.M. (2004) Towards Culturally Relevant Preventive Interventions: The Consideration of Racial Socialization in Parent Training with African American Families. Journal of Child and Family Studies, 13(3), 277­293.
We present a rationale for the inclusion of culture-based parenting practices (i.e., racial socialization) in the design and implementation of empirically based parenting programs with African American families. We begin with a discussion of the limitations of the current parent training literature related to cultural considerations. Second, we examine the cultural and racial contexts of parenting for African Americans, review the literature on racial socialization, and discuss empirical support for considering its inclusion in parent training programs. Third, we examine the extent to which racial socialization operates in low-income African American families by presenting the findings from a qualitative pilot. We conclude by discussing how findings from the qualitative pilot might inform intervention efforts.

Comas-Diaz, L. (1981). Effects of cognitive and behavioral group treatment on the depressive symptomatology of Puerto Rican women. Journal of Consulting and Clinical Psychology, 49, 627-632.
Compared a control, a cognitive, and a behavior therapy group in the reduction of depression in 26 low-income Puerto Rican women (mean age 38 yrs). Ss were identified as depressed by self-report (Beck Depression Inventory), clinical ratings (a revised version of the Hamilton Rating Scale for Depression), and depression behavior rating scales and were randomly assigned to 3 treatment conditions. Five treatment sessions of 1_ hrs each were conducted over 4 wks. Results show a significant reduction in depression for therapy groups and no significant differences between the behavior and cognitive approaches. A 5-wk follow-up assessment revealed that the alleviation of depression had generally been maintained, with a slight advantage for the behavioral approach.

Dai, Yang, Zhang, Shoujie, Yamamoto, Joe, Ao, Ming, Belin, Thomas R., Cheung, Freda, Hifumi, S. Sumiko. (1999). Cognitive behavioral therapy of minor depressive symptoms in elderly Chinese Americans: A pilot study. Community Mental Health Journal. 35(6), 537-542.
There is a high prevalence of suicide among elderly Chinese, and particularly among elderly Chinese women in Mainland China with a prevalence of 19.6 per hundred thousand. Since Chinese individuals may much more highly value education, a cognitive-behavioral package originated by Ricardo Munoz, Ph.D. was adapted for Chinese American subjects. The material was videotaped in eight sessions, approximately 25 minutes in length, to be shown to community subjects who were at least 40 years and over. In addition, a videotape of muscular relaxation techniques was made. A manual written in Chinese about the content of each class, was given to each subject when he/she attended. The experimental group showed significant improvement in the scores in the Hamilton Depression Scale, including the Somatic Subscale in the Hamilton Anxiety Scale. There was no significant improvement in the control group on any of the measures. Thus the study suggests the efficacy of psychoeducational classes in reducing symptoms of depression in non-patient community elderly. Other studies are being conducted among Korean Americans and Japanese Americans in the United States, and also in the Orient among Japanese elderly.

Friedman, S., Smith, L.C., Halpern, B., Levine, C., Paradis, C., Viswanathan, R., Trappler, B., & Ackerman, R. (2003). Obsessive-compulsive disorder in a multi-ethnic urban outpatient clinic: Initial presentation and treatment outcome with exposure and ritual prevention. Behavior Therapy, 34, 397-410.
There are no naturalistic treatment outcome studies in the literature investigating the effectiveness of exposure and ritual prevention across diverse ethnic groups for OCD. We present data on the naturalistic treatment of 62 outpatients with OCD who presented at an anxiety disorders clinic at an anxiety disorders clinic in an inner-city area. More of our African American and Caribbean American patients, compared to Caucasians with OCD, were female and were more likely to be initially diagnosed with panic disorder only. On initial assessment both groups were similar on psychometric measures as well as reporting similar types of obsessive-compulsive symptoms. Both groups showed moderate improvement with treatment, although significant residual symptoms remained. Out results are discussed within the need for further cross-cultural clinical research and outreach.

Ginsburg, G.S., & Drake, K.L. (2002). School-based treatment for anxious African-American adolescents: A controlled pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 41(7), 768-775.
Objective: To evaluate the feasibility and effectiveness of a school-based group cognitive-behavioral treatment (CBT) for anxiety disorders with African-American adolescents. Method: Twelve adolescents (mean age = 15.6 years) with anxiety disorders were randomly assigned to CBT (n = 6) or a group attention-support control condition (AS-Control; n = 6). Both groups met for 10 sessions in the same high school. Key treatment ingredients in CBT involved exposure, relaxation, social skills, and cognitive restructuring. Key ingredients in AS-Control involved therapist and peer support. At pre-and posttreatment, diagnostic interviews were conducted, and adolescents completed self-report measures of anxiety. Results: At posttreatment and among those who attended more than one treatment session, 3/4 adolescents in CBT no longer met diagnostic criteria for their primary anxiety disorder, compared with 1/5 in AS-Control. Clinician ratings of impairment and self-report levels of overall anxiety were significantly lower at posttreatment in CBT compared with AS-Control. Teenagers in both groups reported lower levels of social anxiety from pre-to posttreatment. Conclusions: Findings support the feasibility of implementing a manual-based CBT in an urban school setting. Responder rates among African-American adolescents were similar to those found in studies with white youths.

Hall, G.C.N. (2006). Accessibility and Attitudes: Comment on Lau (2006). Clinical Psychology: Science and Practice, 13(4), 317-320.
Lau (2006) offers a viable approach toward cultural adaptation of evidence-based treatments. Progress in the development of culturally relevant interventions, however, has been slow. In this commentary, I consider reasons for this slow progress, including accessibility for diverse groups and clinical psychologists' attitudes. The limited representation of diverse groups in research samples and in the psychology workforce may be a result of limited funding for diversification. Another reason for the lack of diversification may be psychologists' resistant attitudes. Lau (2006) has created a road map to diversify clinical psychology science and practice, and it is our responsibility as individuals and a field to use this road map to diversify clinical psychology.

Hatch, M.L., Friedman, S., & Paradis, C.M. (1996). Behavioral treatment of obsessive disorder in African Americans. Cognitive and Behavioral Practice, 3, 303-315.
This paper reviews some important features in the presentation, diagnosis, and treatment of obsessive-compulsive disorder (OCD) in African Americans. Some adaptations to the behavioral treatment of OCD in African Americans are illustrated through the use of case examples. The growing awareness in psychology that cultural and ethnic issues are important factors in effective treatment planning forms the basis for the present paper. African Americans with OCD in particular have tended not to seek help in mental health settings, and there is little published research in this area. Thus, many clinicians and researchers may be unfamiliar with issues relevant to treatment issues of OCD in this population.

Hwang, W.C. (2006). The psychotherapy adaptation and modification framework: Application to Asian Americans. American Psychologist, 61(7), 702-15.
Although effective treatments for many mental disorders have been developed, little research has been conducted to determine whether these interventions are effective in treating those from diverse backgrounds. Recent reports have suggested that ethnic minorities are less likely to receive quality health services and that they evidence worse treatment outcomes when compared with other groups. To improve care for those from diverse backgrounds, Western-developed psychotherapies may need to be culturally modified or adapted to become more effective in treating ethnic minorities. This article addresses the need for adapting psychotherapy and provides a conceptual framework for making such modifications. The psychotherapy adaptation and modification framework model is applied to recent Asian American immigrants as an illustrative example. However, it may also serve as a point of departure to adapt therapies for other ethnocultural groups. ((c) 2006 APA, all rights reserved).

Kelly, Shalonda. (2006). Cognitive-behavioral therapy with African Americans. In Culturally responsive cognitive-behavioral therapy: Assessment, practice, and supervision. Washington, D.C.: American Psychological Association, 97-116.
This chapter describes the use of cognitive-behavioral therapy (CBT) with African Americans. The first section of the chapter explores common cultural tendencies that may present challenges to treatment. Next it explores the advantages of using CBT with African Americans. It then considers the limitation of CBT with African Americans. Ideas for modifying CBT for African Americans are provided. Finally, the chapter discusses CBT with African American families.

Kohn, L. P., Oden, T., Munoz, R. F., Robinson, A., & Leavitt, D. (2002). Adapted cognitive behavioral group therapy for depressed low-income African American women. Community Mental Health Journal, 38(6), 497-504.
Examined the degree to which a manualized cognitive-behavioral therapy intervention can be adapted to be culturally sensitive in treating depressed low-income African American women with multiple stressors. The authors describe the adaptations made to an existing intervention, a group treatment developed for depressed low-income medical patients. The authors also describe their evaluation of the adapted treatment in which outcomes of African American women (mean age 47 yrs) treated in the culturally adapted group (n=8) were compared to African American women treated in the non-adapted group (n=10). Following treatment, women in the adapted group exhibited a larger drop in average BDI scores. Implications are discussed in terms of challenges related to