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How do we culturally adapt psychotherapy for ethnic minorities? Although there has been growing interest in doing so, few therapy adaptation frameworks have been developed. The majority of these frameworks take a top-down theoretical approach to adapting psychotherapy. The purpose of this paper is to introduce a community-based developmental approach to modifying psychotherapy for ethnic minorities. The Formative Method for Adapting Psychotherapy (FMAP) is a bottom-up approach that involves collaborating with consumers to generate and support ideas for therapy adaptation. It involves 5-phases that target developing, testing, and reformulating therapy modifications. These phases include: (a) generating knowledge and collaborating with stakeholders (b) integrating generated information with theory and empirical and clinical knowledge, (c) reviewing the initial culturally adapted clinical intervention with stakeholders and revising the culturally adapted intervention, (d) testing the culturally adapted intervention, and (e) finalizing the culturally adapted intervention. Application of the FMAP is illustrated using examples from a study adapting psychotherapy for Chinese Americans, but can also be readily applied to modify therapy for other ethnic groups.
Will culturally adapting psychotherapy improve treatment outcomes for ethnic minorities? Research demonstrates that ethnic minorities are less likely to receive quality health services and evidence worse treatment outcomes when compared with Caucasian Americans (Institute of Medicine (IOM), 1999; United States Department of Health and Human Services (USDHHS), 2001). Bernal, Jiménez-Chafey, & Domenech Rodríguez (2009) report that previous literature addressing cultural adaptation models is not well documented, contributing to the paucity of detailed literature in this area. Although considerable progress has been made in establishing and defining efficacious and possibly efficacious treatments for the general population, relatively little is known about the efficacy of empirically-supported treatments (ESTs) for people from diverse backgrounds (Miranda, Bernal, Lau, Kohn, Hwang, & LaFromboise, 2005; Nagayama-Hall, 2001). As the demographics of the United States (U.S.) change, this critical lacuna in our knowledge along with our under-preparedness to effectively treat ethnic minorities will become more apparent.
Today, mental health providers are faced with the dilemma of (a) implementing an “as is approach” to disseminating ESTsto culturally diverse ethnic groups, (b) adapting ESTsto be more culturally congruent in order to better fit the needs of ethnic clients, or (c) developing new, culture-specific ESTs for each ethnic group. Since the majority of therapists working with ethnic minority clientele in the U.S. are trained in western psychotherapy, developing culture-specific treatments that are based on different healing paradigms make choice number (c) less practical. Moreover, developing novel ethnic-specific treatments for each culturally different group in the U.S. may be prohibitively costly, time consuming, and lead to training difficulties, especially if treatments are based on different theoretical paradigms. Implementing an “as is approach” in disseminating ESTs to ethnic minority clients may not fully address the diverse needs of clients. Therefore, culturally adapting ESTs may be the most responsive and cost-effective approach.
Fortunately, there is growing recognition that mainstream mental health services may need modifications in order to meet the needs of our diversifying population. The American Psychological Association (APA) published a set of guidelines for multicultural education, training, research, practice and organizational change for psychologists (APA, 2003). More specific recommendations for training clinicians to be more culturally competent have also been provided (Comas-Diaz & Jacobsen, 1991; Hardy & Laszloffy, 1992; Lo & Fung, 2003; Pedersen, 1997; 2000; Sue, 1990; Sue, Arrendondo, & McDavis, 1992; Sue, Ivey, & Pedersen, 1996).
In addition, specific culturally adapted therapy programs have been developed and found to be effective (Constantino, Malgady, & Rogler, 1986; Kohn, Oden, Munoz, Robinson, & Leavitt, 2002; Kumpfer, Alvarado, Smith, & Bellamy, 2002; Munoz & Mendelson, 2005; Rossello & Bernal, 1999; Szapocznik, Santisteban, Kurtines, Perez-Vidal, & Hervis, 1984; Ying, 1999; Zhang, Young, Lee, Li, Zhang, Xiao, et al., 2002). Similarly, Nicolas, Arntz, Hirsch, and Schmiedigen (2009) have also demonstrated early success in the development of a cultural adaptation model for Haitian adolescents using the Ecological Validity and Cultural Sensitive Framework (Bernal, Bonilla, & Bellido, 1995), briefly described below, as the cultural foundation for adaptation with the Adolescent Coping with Depression Course (ACDC). There is also growing evidence to suggest that treating clients in a more culturally sensitive manner (i.e., providing client-therapist ethnic matching and treatment at ethnic-specific services) can reduce premature treatment failure (Flaskerund & Liu, 1991; Sue, Fujino, Hu, Takeuchi, & Zane, 1991; Takeuchi, Sue, & Yeh, 1995). A few theoretical frameworks have also been developed to guide therapy adaptations. For example, Bernal, Bonilla, and Bellido (1995) developed a theoretically driven framework for developing culturally sensitive interventions. This framework consisting of dimensions of treatment and culturally sensitive elements has been used to guide adaptations in cognitive-behavioral and interpersonal treatments for depressed Puerto Rican adolescents and these adapted treatments have been shown to be efficacious in randomized controlled trials (Rossello & Bernal, 1996; Rosello & Bernal, 1999). They suggested using 8 different dimensions, including language, persons, metaphors, content, concepts, goals, methods, and context to identify areas for adaptation. For example, the dimension of “context” involves consideration of changing contexts that might increase risk to acculturative stress problems, disconnect from social supports and networks, and reduced social mobility. The dimension of “persons” involves addressing cultural similarities and differences between the client and clinician. Issues of “content” involve cultural knowledge and information about the values, traditions, and customs of the culture. For more information on the framework developed by Bernal, Bonilla, and Bellido, see Bernal, Jiménez-Chafey, and Domenech Rodríguez (2009) and Nicolas et al., (2009).
A more recent framework developed by Hwang (2006) entitled “The Psychotherapy Adaptation and Modification Framework (PAMF) offered a three-tiered approach to making cultural adaptations. It consists of domains, principles, and rationales. Domains identify general areas that practitioners should utilize when modifying therapeutic approaches for their clients. Principles provide more specific recommendations for adapting therapy for specific groups. Rationales provide corresponding explanations for why these adaptations may be effective when used with the target population. This three-tiered approach was created to help practitioners make the shift from abstract ideas of being culturally competent to developing specific skills and strategies that can be effectively implemented when working with diverse clientele. In addition, it was developed to help practitioners thoroughly think through the reasons why they were making certain adaptations and to support these modifications with compelling reasons. General domains for adaptations include: (a) understanding dynamic issues and cultural complexities, (b) orienting clients to psychotherapy and increasing mental health awareness, (c) understanding cultural beliefs about mental illness, its causes, and what constitutes appropriate treatment, (d) improving the client-therapist relationship, (e) understanding cultural differences in the expression and communication of distress, and (f) addressing cultural issues specific to the population. Specific principles and rationales are detailed more fully in Hwang (2006).
Although theoretically driven approaches to cultural adaptation provide a strong foundation for tailoring interventions, bottom or ground-up community-based approaches can also provide invaluable information by confirming theory-related adaptations, generating ideas that more theory-driven approaches leave out, or by providing more specificity in the adaptations or examples offered. Community-based formative approaches to therapy adaptation can also serve as a powerful tool for cultural understanding because they involve consumers (therapists and clients), as well as community stakeholders and collaborators. A few studies have been published that have proposed frameworks and recommended sequences for developing culturally adapted interventions. For example, in discussing parent training, Lau (2006) recommended an evidence-based approach that (a) prioritizes selectively targeting problems and identifying communities that would most benefit and (b) using direct data outcomes to justify adaptations. In a response to Lau, Barrera and Castro’s (2006) commentary recommended a sequence involving (a) information gathering, (b) preliminary adaptation design, (c) preliminary test of the adapted treatment, and (d) adaptation refinement, which is similar to the model presented below. Domenech Rodriguez & Wieling (2005) proposed a Cultural Adaptation Process Model, consisting of three phases, (a) focusing on the iterative process among all those involved in the adaptation process, (b) selection and adaptation of evaluation measures and continual exchange between the community and those creating the adaptations, and (c) integrating the observations and data gathered in phase two to create a new intervention. These models argue that community-based approaches will increase ecological validity of adaptations by increasing community participation. Nicolas et al. (2009) provide an additional example of a community-based cultural adaptation model for working with Haitian adolescents where the authors outline specific steps taken to build collaborative relationships with the community as a way to adapt the ACDC in a culturally responsive manner. A book on culturally responsive cognitive-behavioral therapy with different groups has also been published (Hays & Iwamasa, 2006). See also Hays (2009) for a more recent discussion of the integration of cognitive behavioral and multicultural therapies and their effectiveness in psychotherapy.
The purpose of this paper is to introduce the Formative Method for Adapting Psychotherapy (FMAP) framework, a community-based bottom-up approach for culturally adapting psychotherapy. It was developed to be used in conjunction with the top-down PAMF (Hwang, 2006) to generate ideas for therapy adaptation, provide additional support for theoretically identified modifications, as well as to help flesh out and provide more specific and refined recommendations for increasing therapeutic responsiveness. It was generated in parallel to other adaptation models and contributes to the growing body of literature on culturally responsive treatment development. The combination of the top-down PAMF and the community-based FMAP approaches were developed by the Principal Investigator (PI) as guiding frameworks to facilitate the creation of a new culturally adapted treatment manual for depressed Chinese Americans. This culturally adapted Cognitive-Behavioral Therapy (CBT) manual is currently being tested against a non-culturally adapted CBT manual in a National Institutes of Mental Health (NIMH) funded clinical trial on empirically supported adapted interventions. Because the PAMF has already been described in a previous report by Hwang (2006), this paper focuses more on introducing the more bottom-up FMAP framework.
The FMAP approach consists of 5-phases: (a) generating knowledge and collaborating with stakeholders (b) integrating generated information with theory and empirical and clinical knowledge, (c) reviewing the initial culturally adapted clinical intervention with stakeholders and revising the culturally adapted intervention, (d) testing the culturally adapted intervention, and (e) finalizing the culturally adapted intervention. Each of the phases of the FMAP model is described below and can be tailored to meet the individual needs of different projects. Moreover, application of the FMAP is illustrated through examples from an ongoing clinical trial. The cultural adaptation process described here overlaps with the model described by Nicolas et al. (2009), and it is hoped that in conjunction both models can be used as guides for future research and practice.
The first step of implementing the FMAP is to decide which stakeholders to involve and when to involve them. According to the FMAP, there are generally six main categories of stakeholders, including (a) mainstream health and mental health care agencies, (b) mainstream health and mental health care providers, (c) community-based organizations and agencies, (d) traditional and indigenous healers, (e) spiritual and religious organizations, and (f) clients. For the purposes of our adapting CBT for Chinese Americans project, conscious decisions were made to include the following stakeholders initially: (a) Asian focused community mental health service agencies, (b) mental health providers (psychiatrists, psychologists, social workers, marital family therapists), (c) Traditional Chinese Medicine (TCM) practitioners, (d) Buddhist monks and nuns and both spiritual and religious Taoist masters. These stakeholders were included because they have expertise in treating depressed Chinese Americans and could potentially provide direct feedback on developing and improving treatments. Eliciting client feedback is also important, however, this was done later in the process for several reasons, including that (a) many of the clients had little to no exposure to mental health services, (b) were ill and could potentially lose confidence in treatment if project staff ask them for treatment advice, and (c) had minimal ability to differentiate types of treatments offered before receiving them. Client feedback is more extensively elicited in Phases IV and V.
Asian focused clinics were included because we wanted to make sure that the intervention developed could be feasibly implemented in the parameters of real treatment centers (e.g., the frequency of sessions, staffing and assignment of caseloads, hours of operation, billing and financial limitations), and to ensure that the program developed would be sustainable. For the purposes of our project, we collaborated with seven Asian focused clinics, two of which served as primary clinical trial sites and five as focus-group collaborators. Focus groups were not run at clinical trial sites to ensure that treatment conditions would not be contaminated.
Mental health care providers were asked to participate because they are experts in the field and have insights and expertise in working with depressed Asian American clients. In addition, getting practitioners to participate in developing the intervention facilitated their buy-in to the treatment. Two four-hour focus groups with each clinic were run and multiple focus groups were run at larger clinics. Each focus group consisted of four to six mental health practitioners with a range of clinical experiences. This helped facilitate both breadth and depth of discussions. The first four hours involved general discussions of cultural adaptation and review of different treatment manuals and interventions. Specifically, we asked therapists their impressions, whether different aspects of treatments would work, and also elicited feedback about how best to modify them for Asian Americans. It was important to involve multiple clinics because they each possess different characteristics, biases, and notions about best practices. Capturing a range of feedback allowed us to develop a less biased and more ecologically valid treatment. Because we wanted to create an intervention that could be more easily modified for other Asian groups in the future, focus groups included staff that treated Chinese American and other Asian Americans. Interviews were also conducted with Traditional Chinese Medicine (TCM) practitioners, Buddhist monks and nuns, and spiritual and religious Taoist masters. It was important to involve cultural healers because these traditions have strongly influenced Chinese culture for thousands of years. This also provided an opportunity to exchange ideas, build a sense of community, and strengthen referral networks.
Information generated from our community-based focus groups was synthesized with the PAMF framework, extant theories, empirically supported therapy literature, my previous experience conducting therapy in a variety of community-based settings, and my continued private practice experience. The PI then began writing a new culturally adapted cognitive-behavioral therapy manual. Details of the adaptations made are presented later in this paper. Focus group collaborations helped reduce personal, clinician, and agency specific biases. Collaborating with traditional healers also helped ensure that cultural adaptations were grounded in cultural belief systems. Because not all of the stakeholders possess similar opinions of what therapeutic modifications would be most beneficial to the clients, the most recurrent themes were used and the author finalized the treatment manual based on his experiences and discussions generated.
After writing the culturally adapted manual, four additional hours of focus groups were conducted with the therapists. Focus groups were conducted in English, with some portions being discussed in Chinese when beneficial. Initial impressions of the new intervention (English and Chinese versions) and feedback for improvement were elicited. Feedback was used to finalize the manual before clinical trial implementation. The final manual was titled “Improving your mood: A culturally responsive and holistic approach to treating depression in Chinese Americans” (Hwang, 2008; 2008). Client and therapist manuals were written, and translations into Chinese were conducted throughout the treatment development process and further refined and finalized after the focus groups were completed. Translations of the treatment manuals as well as assessment measures used in the clinical trial involved forward and back translation by a team of four master’s level therapists, one postdoctoral fellow, and the author. In addition, feedback from 15 undergraduate students, three master’s level therapists, one postdoctoral fellow, and four graduate students was elicited. Because of the linguistic variability even within the written Chinese languages, translators spoke languages from different Chinese regions and countries (e.g., mainland China, Hong Kong, Taiwan).
The final intervention includes a 12 week program and is currently being used in a clinical trial funded by the National Institute of Mental Health (NIMH). A variety of clinical and cultural outcome measures (from clients, therapists, and independent assessors) are being used to test the efficacy of the interventions, including symptom reduction, treatment satisfaction, premature dropout, working alliance formation, and receipt and enactment of therapy. Assessments are collected at multiple time-points (e.g., baseline, week 4, 8, 12, and 3 months after the treatment has ended). All therapy sessions are also being recorded for qualitative therapy process review and weekly ongoing supervision is provided to the therapists in both adapted and non-adapted conditions by the author. Although having one supervisor for both conditions could potentially lead to allegiance biases, the use of different supervisors could also lead to a supervisor effect. Because the NIMH R34 grant is a treatment development grant, having one supervisor supervise both treatment conditions was deemed the best option because supervision information gathered will also be used to further refine the treatment after the clinical trial is completed.
Clients who finish the treatment will be asked to participate in an interview to elicit feedback regarding their experiences, what they found useful, what they did not like, and their recommendations for treatment improvement. Therapists will also participate in an exit interview, both individually and as a group so that additional recommendations can be integrated. The PI will use this information along with his experiences supervising both treatment conditions and finalize the treatment manual. Therapist focus groups will again be conducted on the finalized manual, and focus groups consisting of community participants will also be used to finalize changes.
Although the clinical trial that was used to illustrate the stages of the FMAP has not been fully completed, the information generated from phases I thru III were effective in producing a culturally adapted manual that will be further refined after the clinical trial is completed. Table 1 lists the cultural adaptations that were used to create the new manual for depressed Chinese Americans. It is a culmination of adaptations generated by research and clinical theory (Phase II) and from more formative focus group process (Phases I and III). Below, it is presented in the same format as the PAMF, with adaptations arranged under different domains of adaptation, specific principles of adaptation, and corresponding rationales to justify why modifications were made. Comparison with the original PAMF table (see Hwang, 2006) reveal similar adaptations, however, the new cultural adaptation table are expanded, more specific, and provide more detailed and concrete recommendations. More theory driven PAMF adaptations were retained in the table only if reaffirmed by the more generative FMAP stages.
The development and modification of therapeutic interventions to match the client’s cultural background is essential if we are to provide high-quality and culturally responsive treatments. This is especially important since the concept or notion of psychotherapy and the rationale behind therapeutic treatments may be culturally unfamiliar, foreign, and stigmatizing to many groups. The goal of this paper was to introduce the FMAP framework and we hope that clinical researchers will find this stage-by-stage bottom-up approach to cultural adaptations beneficial. Comparing the efficacy of evidence-based adapted interventions with non-adapted interventions will be important in improving care for ethnic minorities.
This study was supported in part by National Institute of Mental Health (NIMH) grant 1R34MH73545-01A2 and the Asian American Center on Disparities Research (NIMH grant: 1P50MH073511-01A2).
WEI-CHIN HWANG received his PhD in clinical psychology from the University of California, Los Angeles (UCLA). He is an Associate Professor of Psychology at Claremont McKenna College. His areas of research include ethnic, racial, and cultural issues in mental health and developing cultural competent and effective interventions for ethnic minorities.
Editor’s Note: This article is one of four in this special section on Evidence-based Practices and Multicultural Populations.—MCR
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