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Through the Foundation's investigation of approaches to advancing culturally competent mental health service delivery in Texas, cultural adaptation was quickly identified as an area in which the Foundation could make a significant contribution. In November 2005, the Foundation convened two expert panels to determine what is known about using mental health treatments touted as "evidence-based" with populations of color. The panels made it clear that there was much to be learned about the process of cultural adaptation. Cultural Adaptation: Providing Evidence-Based Practices to Populations of Color is the first initiative in the Cultural Competence priority area. Funds in this initiative were distributed via a competitive Request for Proposals (RFP) review process. In July 2006, the Foundation announced awards of more than $2.9 million over three years to five organizations to adapt the delivery of evidence-based practices (EBPs) to be compatible with the cultures of their populations of color. With the help
of cultural competence and EBP experts, the Foundation is working
with the Cultural Adaptation over the three year period to identify
effective ways to modify EBPs for populations of color. Lessons
learned will be used to inform research and service delivery in
this critical area. •
Why is the Foundation focusing on cultural adaptation? Why
is the Foundation focusing on cultural adaptation? Texas is now a "majority-minority" state, a status held only by Hawaii, New Mexico, California, and the District of Columbia. Just over half of the Texas population is ethnic and racial minorities, according to the U.S. Census Bureau's 2004 population estimates. The four major groups of color in the U.S. African Americans, Asian Americans, Latinos, and Native Americans are well represented in Texas.
Public and private mental health systems have been slow to address the needs of these burgeoning 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 health care, including mental health services. They are more likely to be uninsured, which results in less access to preventative care, reduced ability to obtain prescription medications, higher rates of avoidable hospitalizations, and later-stage diagnosis of health problems. Even when ethnic minorities do have access to mental health services, the quality of care they receive is often poor, as are the outcomes of that care. At the national level, ethnic and racial disparities in access to quality mental health services were prominently highlighted in the final report of the President's New Freedom Commission on Mental Health. The subcommittee on cultural competence's report to the President concluded:
As a consequence, a key recommendation in the commission's final report was to "improve access to quality care that is culturally competent." This recommendation is an acknowledgment of the fact that current approaches to mental health services delivery are not "universal," which has been the field's stance to date. One cannot take for granted that a psychological treatment that is effective for one ethnic/racial group will work with all groups. Even when a psychological treatment is beneficial for all ethnic/racial groups, its delivery will still need to be tailored to meet the unique cultural experiences of different groups. Decades
of research have shown that there are important ethnic and racial
differences in how people conceptualize 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 must be incorporated into
any treatment approach if it is to be beneficial for different ethnic
/ racial groups. That is, all treatments must be adapted to be congruent
with the culture of the target population. Such cultural adaptations
are the focus of the Foundation's Cultural Adaptation Initiative.
Before jumping into the process of cultural adaptation, it is useful to define its building blocks: culture and cultural competence. What is culture? Definitions of culture vary significantly. Some people conceptualize culture as ethnic identity or nationality, a notion reflected in the common use of categorical labels like "Latinos" and "African Americans," which fail to recognize the importance of within-group differences. Some conceptualize culture in terms of the events, celebrations, foods, and music of a group of people. Although both of these identify aspects of culture, they fail to capture its true scope. Guarnaccia and Rodriguez (1996) assert that culture is not static. It is not just a thing, but also a process that impacts everything we do, know, and perceive:
In
the mental health care setting, culture impacts how people: What is cultural competence? Davis (1997) defines cultural competence as 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. Cultural competence occurs in mental health service delivery when cultural issues are acknowledged and addressed at all levels of an organization administration, service delivery, and clinician. At the 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 many others. At the 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. At
the clinician level, cultural competence impacts the therapeutic
relationship between the clinician and client, supporting the client's
participation in treatment. Clinician-level cultural competence
is difficult to describe in terms of specific strategies. It is
best understood as a stance. Whaley (2003) describes a culturally
competent provider as someone who: At all levels, cultural competence is not an endpoint, but an ongoing process of assessing people's needs and incorporating what is learned into the provision of services. View a Selected Annotated Bibliography of key articles on cultural competence and learn more about strategies for developing cultural competence.
What is cultural adaptation? Cultural adaptation is the process of adjusting the delivery of mental health services to be consistent with the client's culture. The provision of services is adapted to the culture. Simply put, cultural adaptation is the process of modifying mental health service delivery to make it culturally competent. Just as cultural competence must be addressed at the administrative, service delivery, and clinician level, so must cultural adaptations be developed on all three 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. View a Selected Annotated Bibliography of key articles on adapting treatments for people of color. What are evidence-based practices (EBPs)? In the United States, the development of evidence-based practices (EBPs) has been a major force in improving the quality of mental health services. The movement toward EBPs emphasizes using treatment approaches that have research support. Treatments like cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) which have been shown to be efficacious in numerous treatment studies across researchers are considered more likely to yield positive outcomes for clients than treatments without such data. EBPs like CBT and IPT are being adopted and promoted by insurers and state and local governments around the country in the name of increasing quality of services and optimizing financial investments. The campaign for evidence-based practices has been led by the American Psychological Association's Division 12 Task Force on Promotion and Dissemination of Psychological Procedures, which first published a report on empirically validated treatments in 1995. The task force modeled its criteria for determining treatments' efficacy after the Federal Drug Administration's. The APA task force has defined two levels of EBPs well-established treatments and probably efficacious treatments. Well-Established Treatments are psychological treatments that have been shown to be either superior to placebo or to another treatment or equivalent to an already established treatment across two or more between-group design experiments or 10 or more single-case design experiments. The studies must have included the use of treatment manuals and a clear description of the client samples' characteristics, and the treatment's efficacy must have been demonstrated by at least two different researchers or research teams. Probably
Efficacious Treatments are psychological treatments that research
support but not to the extent of well-established treatments. Support
for probably efficacious treatments may be demonstrated by: View a Selected Annotated Bibliography of key articles on EBPs. Applying the APA's criteria, psychologists have identified multiple EBPs for the major psychiatric diagnoses seen in adults and children. At present, the following treatments can be considered evidence based: Depression Anxiety
Disorders Attention
Deficit - Hyperactivity Disorder Externalizing
Disorders What is the evidence for using EBPs with people of color? Although providing EBPs for people of color with mental illnesses would appear to be a logical way to increase the quality of care received and its outcomes, this approach has been controversial. A key criticism of EBPs is that the research on which treatments' efficacy is evaluated rarely gives sufficient consideration to 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 in their treatment samples. What demographics are represented in these studies' treatment samples? Clients who participate in psychotherapy research tend to be Anglo, female, educated, and middle or upper class. Critics rightly question the external validity of research on this select population. That is, does it make sense to generalize findings from studies of a relatively small, privileged, ethnically homogeneous slice of the U.S. population to other segments of our society? In 2005, Miranda and colleagues conducted a comprehensive review of the research support for the effectiveness of various EBPs with ethnic minorities. They identified studies in which various EBPs were used with children and adults of color. Miranda and colleagues (2005) found evidence to support using EBPs for depression, anxiety, ADHD, and externalizing disorders with African American and Latino youth. There has been too little research with Asian American youth to draw conclusions about EBPs' usefulness with that group. For adults, they found support for using EBPs for depressive disorders, anxiety disorders, and psychotic disorders with Latinos, African Americans, and to a lesser extent Asian Americans. No research has been conducted on using EBPs with Native American children or adults, so Miranda and colleagues were unable to conclude anything about EBPs' usefulness with that group. The results of these studies indicate that, although the research is limited, EBPs can yield positive outcomes for ethnic minorities. View a Selected Annotated Bibliography of key articles on EBPs and people of color. How can the delivery of EBPs be adapted for various populations of color? 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. As noted above, there is no one way to culturally adapt mental health services. The best way to do so depends on the cultures 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 is essential, as is creative, thoughtful translation of those assessment findings into action at the administrative, service delivery, and clinician level. In their 2005 review of the literature, Miranda identified numerous studies in which culturally adapted EBPs yielded positive outcomes for ethnic minority clients. In some studies of EBPs with ethnic minorities, the EBPs were delivered exactly as they had been used with ethnic majority clients. Others involved a cultural adaptation of the treatments, in which the basic therapeutic interventions remained intact but culturally appropriate issues and concerns were woven into the treatment or culturally appropriate adjunct services were added to the treatment. Miranda et al.'s (2005) article, which summarizes these studies, and other articles on culturally adapted care are cited in the Selected Annotated Bibliography. There are not sufficient data available to determine whether cultural adaptations are superior to standard EBPs. However, given the significant ethnic/racial differences in how people conceptualize mental illness, recognize their own distress, communicate their distress to others, seek help, and participate in treatment, it seems likely that culturally adapted services are more likely to yield greater positive outcomes for ethnic minorities. Culturally competent care is effective care. What are the Foundation's objectives for the Cultural Adaptation Initiative? The Foundation's objectives for the initiative are to increase the availability of effective mental health services for people of color and to generate knowledge about cultural adaptations of EBPs. To fulfill these objectives, the Foundation is partnering with community mental heath providers to adapt how they deliver EBPs to reflect the cultures of their populations of color. Learn more about the Cultural Adaptation grant program. Mental health providers who serve populations of color will select an EBP from a list compiled by the Foundation. The list is based on the available research evidence for the most common psychiatric disorders. The mental health providers' staff will receive training in the EBP, and over the grant period they will implement a cultural adaptation of the EBP to overcome the cultural barriers of their treatment population. The cultural adaptation will occur at the administrative, service delivery, and clinician levels. Organizations will assess the outcomes of the culturally adapted treatment and participate in an evaluation across all grantee organizations to understand how the cultural adaptations were developed and implemented, for the purpose of aiding other organizations interested in cultural adaptation. View
the Evidence-Based Treatments
for the Cultural Adaptation Initiative. The Foundation is looking for organizations skilled in working with people of color to actively partner with us to adapt the delivery of EBPs for populations of color in Texas. We will work with our grantees over a three-year period to provide EBPs in culturally consistent ways and evaluate the impact of their adaptations. We will convene our grantees throughout the grant period to facilitate problem solving and knowledge sharing. We will hold regular teleconferences, so that grantees can troubleshoot and learn from each other. Grantees will attend an annual meeting at the Hogg Foundation for Mental Health, during which they will have the opportunity to discuss their work with Foundation staff and experts in cultural competence and related fields. Foundation staff will also make annual site visits to learn more about the grantees' work and to assess their needs for additional support. Grant
Program •
Expert Panels • Assessment
Tools • Evidence-Based
Practices |
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©
2006 Hogg Foundation for Mental Health
The University of Texas at Austin |
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