The number of ethnic minorities in the United States continues to grow rapidly (U.S. Census Bureau, 2008
), and with this growth comes a need for increased mental health services research with diverse populations (USDHHS, 2001
). This study addressed several major gaps in the literature concerning psychotherapy outcome and process with ethnic minority populations, particularly for Asian Americans who comprise the second fastest growing ethnic group in the United States (USCB, 2008
Given the limited treatment outcome research with Asians (Leong & Lau, 2001
), the most basic question concerns whether established therapies actually work with this population. As expected, both active treatments outperformed self-help at post-treatment and follow-up. These results are in line with previous research showing the efficacy of in vivo exposure for specific phobias (Choy et al., 2007
; Öst, 1997
) and with recent randomized trials showing that evidence-based treatments can work with Asian Americans (Otto et al., 2003
; Shin, 2004
). Despite the modest sample size and sample homogeneity, our findings suggest that OST is an efficacious treatment for Asian Americans.
We also found that OST-CA was more effective than OST-S for two phobia-related outcomes: general fear and catastrophic thinking. These findings are notable because while it was expected that both versions of OST would be effective at reducing phobic symptoms, the superiority of OST-CA for several outcomes suggests that our cultural adaptations provide benefits that extend beyond the standard course of treatment.
Importantly, OST-CA effects were not uniform across participants. As expected acculturation level moderated therapy outcomes, with low-acculturation Asian Americans benefiting most from culturally-adapted treatment. To date, there is minimal treatment outcome research examining the moderating effects of acculturation with ethnic minorities (Martinez & Eddy, 2005
; Telles et al., 1995
) and none that include Asian American populations. Among Asian Americans, acculturation level appears to affect many therapeutic variables such as working alliance (Kim et al., 2002
; Kim & Omizo, 2003
), attitudes towards seeking mental health services (Liao, Rounds, & Klein, 2005
), and perceived therapist credibility and competence (Gim, Atkinson, & Kim, 1991
). It is possible that the cultural adaptations better addressed concerns that low-acculturation individuals held regarding the utility of therapy more broadly and exposure more specifically. Although not assessed in this study, these participants may have perceived OST-CA as more comfortable and credible, thus leading to greater treatment benefits.
Of course, one critical question pertains to why
cultural adaptations might enhance treatment effects for ethnic minorities. Although theories of multicultural counseling tend to agree that matching therapy context with the minority client’s worldview enhances treatment effectiveness (Fuertes & Gretchen, 2001
), they say little about potential mechanisms of action. In this study, we tested several possible mechanisms derived from therapist and participant report and observer ratings of therapy process. We found that working alliance and cultural process factors were predictive of positive therapy outcomes. Although none of these factors mediated treatment effects, previous research shows that working alliance is consistently associated with treatment outcomes (Horvath, 2006
). Moreover, a small number of studies report that cultural process may predict treatment outcomes for minority participants (Gil, Wagner, & Tubman, 2004
; Jackson-Gilfort, Liddle, Tejeda, & Dakof, 2001
Notably, exposure and exposure duration were associated with increases
in SUDs and therapist-rated fear over time. This finding was unexpected given that exposure is a core element of our treatment and that major theories (e.g., Foa & Kozak, 1986
) place a heavy emphasis on exposure as a primary component of anxiety-focused interventions. However, rather than suggesting that therapist-directed exposure increases phobic anxiety, we argue that treatment refractory cases may have required significantly more exposure time. Thus, one possibility is that poorer responders were more reticent to approach the phobic stimuli, thus extending the amount of time spent in session trying to engage participants. By contrast, those who were more willing to engage early in treatment may have habituated more easily, advanced through the steps of their fear hierarchy more quickly, and therefore exhibited less post-treatment fear.
Additionally, these findings suggest that properly designed and integrated cultural adaptations can be very subtle, yet still effective. A manipulation check was conducted after each OST session that asked participants to report whether they thought they had completed the standard or culturally-adapted intervention. Every participant, regardless of OST condition, thought that they had participated in the standard course of OST. Thus, despite the understated nature of our cultural adaptations, participants appeared to benefit nonetheless. Another advantage is that the cultural adaptations did not appear to lead to an increase in treatment load (i.e., sessions were not longer for OST-CA participants) nor interfere with important treatment processes such as working alliance.
Though this study has many strengths, it also has several limitations, the first relating to sample size. The modest number of participants may not have provided the requisite power to detect significant effects for mediation analyses, a common problem with randomized trials (Kraemer, Frank, & Kupfer, 2006
). Though full mediation analyses could not be conducted, it is encouraging that many of the conditions for mediation testing were met despite the limited sample size. Additionally, some of the moderation analyses reported were marginally significant (p
< .10) and should be interpreted with caution. However, given the pilot nature of this study and the dearth of research on this topic, we thought it important to report these marginally significant trends to inform future research.
Other limitations include the restricted sample of undergraduate Asian Americans with specific phobias. Thus, our cultural adaptation findings may not be readily generalized to populations who differ with respect to age, ethnicity, or diagnostic status. Additionally, all assessments and treatment sessions were conducted by one individual, the first author, which may have contributed to unintentional cross-contamination. However, this may be less of a concern given that the adaptations were found to be subtle and not discernible by participants, but identifiable by trained independent coders. Finally, it remains unclear which of the cultural adaptations work optimally, although therapy process analyses suggest that emphasizing emotional control and the vertical nature of the therapist-client relationship were most important.
Despite these limitations, this study might serve as a one model for how to design and evaluate treatment adaptations for diverse minority groups. Notably, our cultural adaptations were theory-driven yet derived exclusively from empirical research, an approach congruent with recent calls to action regarding interventions for minorities (Bernal, 2006
; Hwang, 2006
; Lau, 2006
). Also, prior research focused primarily on comparisons of culturally-adapted treatments to no treatment or placebo control (e.g., Hinton et al., 2004
; Otto et al., 2003
; Rosselló & Bernal, 1999
), which leaves lingering questions concerning the unique contribution of cultural enhancements. This study is one of the few to isolate cultural process effects in a clinically-indicated sample (also see McCabe & Yeh, 2009
; Szapocznik et al., 1986
), and may be the first to show that treatment gains are attributable to culturally-oriented modifications of a well-established intervention.