Yale Psychiatry Grand Rounds: September 23, 2022

September 23, 2022

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"Evidence-Based Treatments for Ethnic Minorities: Does Cultural Competence Matter?"

Stanley J. Huey, Jr., PhD, Associate Professor of Psychology and American Studies and Ethnicity, University of Southern California

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00:00For the. For the invitation and for the
00:08opportunity to discuss a topic that I really
00:11like to talk about and and that's making.
00:15Treatments evidence based
00:18treatments more specifically fit.
00:21For the diverse populations who who
00:23I would argue need them the most,
00:25and nowadays I'm also much more open about
00:28my personal motivations for doing this work.
00:32Umm, my younger brother had
00:36significant mental health. Um.
00:39Behavioral substance use problems
00:40as a kid and then later as an adult
00:44and spent many of his years in the
00:47public mental health system and the
00:51criminal justice system and a few years
00:56ago committed suicide while while
00:58incarcerated and and I don't blame
01:00our public mental health system for
01:03for that his trajectory and outcome,
01:05but I I can't help but wonder.
01:08That if the if the system had
01:11been more responsive to his.
01:13And to his needs,
01:15whether he might still be with us or not.
01:18I I forgot kind of starting
01:20with the depressing note,
01:21but I I think that kind of context
01:23is is important just to kind of
01:25understand how how I entered this work,
01:27but I I forgot the disclosure statement,
01:31just wanted to quickly show this to you.
01:37Nothing to disclose,
01:39so let let me real things back.
01:44Bit and talk about another kind of stream
01:48of motivation for this sort of work.
01:50It was back in Graduate
01:53School when Antonio Polo,
01:54fellow,
01:55graduate student of mine in my lab
01:57and and I started to think about
02:00whether psychotherapies work for ethnic
02:02minorities and what role culture.
02:05Played,
02:05and we started grad school at UCLA,
02:09working with John Weiss,
02:10who was in the psychology department
02:12at that time.
02:13And it was also a time when the
02:16empirically validated treatments
02:17movement in psychology was really
02:19kind of picking up and moving forward,
02:22and we were a cognitive,
02:23behaviorally oriented program,
02:24so it was a good fit.
02:27For our program, but, you know,
02:29I'm I'm African American.
02:31If you had discerned that Antonio Polo,
02:33my fellow grad students,
02:35is Mexican American,
02:36and as we were learning to be clinicians,
02:39we we were learning CBT.
02:41But we also kind of intuitively,
02:44given our own personal narratives
02:47and experiences,
02:48felt that culture was an important
02:51consideration when we're working
02:52with culturally diverse population.
02:54So as we were being trained,
02:56we were also doing things.
02:57Suddenly enough,
02:58so subtly in terms of tweaking,
03:00adapting, modifying,
03:02integrating cultural issues
03:04and into our clinical.
03:08Processes and and this,
03:11this mode that we sort of took
03:13on an intuitively was consistent
03:15with arguments that a number of
03:18prominent scholars at the time,
03:20including Stan and Sue who is
03:22in our department had concerning
03:23how important culture was and he
03:26he coined something called the
03:28cultural responsiveness hypothesis.
03:30And what's something like this?
03:32There are potential problems
03:34with conventional therapies and
03:36that that includes.
03:37He's so, so-called evidence based therapies.
03:41They were developed for White,
03:43Western, English speaking individuals.
03:45For the most part.
03:47The majority of clinicians were at
03:49that time and still are white and
03:52generally they didn't in a clear,
03:55overt way consider the language beliefs
03:58and worldviews of culturally different.
04:01Individuals and the the argument
04:03was that if culture is ignored or
04:06minimized in the clinical context and
04:08there are going to be values conflicts
04:12between the clinician and the client,
04:14they're going to be miscommunication
04:16between the clinician and the client.
04:18And that's going to, of course,
04:20lead to greater client discomfort
04:24and poor engagement.
04:26In treatment, if clients cultural
04:30diverse clients are not engaged,
04:33well, they're going to drop out.
04:34If they drop out then they're not
04:36going to benefit from treatment.
04:38There's going to be treatment failure.
04:39So the the argument was that treatments
04:42need to be culturally responsive,
04:45culturally sensitive in some
04:47way and or the clinicians need
04:50to be culturally competent.
04:53When providing mental health
04:55services to diverse populations,
04:56and this all made sense.
04:58To us.
04:59So Antonio and I decided,
05:01given that we work with an
05:03advisor who did meta analysis,
05:05we we started to conduct our
05:07own meta analysis to try to
05:10answer 3 critical questions.
05:11Concerning treatment outcomes
05:13with ethnic minority youth,
05:14because we had that particular interest
05:16and we thought we knew the answers
05:18to each of these three questions.
05:19So first, our mental health treatments.
05:21Affective with ethnic minority youth,
05:24we thought, well,
05:24sometimes maybe, but often not,
05:26given who these treatments by
05:28and large were developed for.
05:30Do white youth benefit more than ethnic
05:32minorities from the same treatment?
05:33Well,
05:34of course white youth are going to
05:36benefit more from these standard,
05:39culturally sort of neutral
05:41interventions for the most part.
05:45And then third,
05:46do cultural adaptations enhance
05:48outcomes for ethnic minorities that
05:50are thinking was definitely well,
05:53it turns out that the answers to all
05:54three of these questions were way more
05:56complicated than we initially thought.
05:58And given the amount of work we had
06:00to do with our initial meta analysis
06:02that was ultimately published in 2008,
06:04we we actually had to buy a hand
06:07go through 1000 plus randomized
06:10trials to to call about 30 or so.
06:14That that focused sort of primarily or in
06:18some significant way on ethnic minorities.
06:21We we we found some answers
06:22that surprised us.
06:23So I'm going to sort of in this
06:26talk for the next 35 minutes or so
06:29try to answer four key questions.
06:32Are treatments effective with
06:34ethnic minorities?
06:34Are treatment outcomes worse for ethnic
06:37minorities compared to Euro Americans?
06:39This cultural tailoring enhance treatment
06:42outcomes for ethnic minorities?
06:45And then finally,
06:47given some of the skepticism that
06:49sort of comes through in my responses.
06:52To those three questions that
06:54does culture matter?
06:55OK, first question,
06:57are therapies effective with ethnic?
07:00Minorities.
07:00Before I dive into this,
07:02I need to take about a minute
07:04to give it an extremely brief
07:07primer on meta analysis.
07:08Some of you may be familiar with it,
07:10but I I find it's always helpful to
07:13say something briefly.
07:14Basically, it's a quantitative review
07:16of a literature and in in this case,
07:18therapy effects with ethnic minorities,
07:21and it involves finding all the randomized
07:27trials you can find that deal with.
07:30Treating for these psychosocial
07:33interventions ethnic minority populations
07:36where you have at least one active
07:38treatment compared to a control condition
07:41in the context of a randomized trial.
07:43And we. Call from these studies
07:48something called an effect size,
07:50which is basically the the average outcome
07:53for those in the treatment condition,
07:57say for depression.
08:00And you subtract from that treatment
08:04condition average the average outcome
08:06for those in the control condition,
08:09so treatment outcome.
08:14Average minus the control outcome
08:18average divided by something called
08:20the pooled standard deviation,
08:22which I am not going to get into and that
08:26gives you this effect size essentially.
08:29And basically an effect size of
08:32.8 is what we're shooting for.
08:33It's really what we want.
08:34We want a robust,
08:36strong effect of our psychotherapy.
08:38We want it to be pretty powerful,
08:40but a medium effect is pretty good too.
08:42And the psychotherapy outcome literature,
08:44broadly, medium effects are the norm.
08:47So if we get something around .5 or so,
08:49we're, we're, we're, we're in good shape,
08:51we're happy there .2 or thereabouts or below.
08:55This is kind of a small effect if we get.
08:59.2 or thereabouts,
09:00where I guess that's OK, but you know,
09:03we're not going to be as happy with that.
09:05So .2 ish or so, small effect,
09:09.5 medium effect and .8
09:11and above largest effect.
09:13OK.
09:13So that I think that's basically what
09:15you need to know to understand the
09:17rest of what I'm going to present.
09:19So I'm going to now present
09:22some meta analytic data,
09:23a lot of it from my lab,
09:25but also from other scholars is as well.
09:29When you see bolded names that those are
09:32just my current and former graduate students.
09:35I just want to give them more credit
09:37now in in my presentations to let
09:39them know I don't do this work alone,
09:41but I have a lab for the grad students
09:43who really helped make this work
09:45as well as other collaborators.
09:46So this is data from 5 meta analysis
09:50that are published or that are in
09:53progress or kind of in in the pipeline.
09:57And you can see there's a range.
10:00The highest affect size that we've
10:03found with a particular population
10:05is one that we published in 2018
10:08focused on treatment outcomes
10:10with Asian American population.
10:12So a .72 effect, almost a large effect.
10:16The lowest that we found for a kind
10:20of is .37 like for ethnic minorities
10:23with substance use problems.
10:25But overall, if you average across these,
10:27you get an effect size.
10:28About .5 in the medium range.
10:32And this is taking this is a
10:35figure taken from a summary.
10:38Graph that we published in this
10:40paper in the annual review of
10:43clinical psychology in 2014.
10:46Synthesizing info from a
10:48database that we collected up to
10:51that time and again,
10:52you see a lot of variation in terms of
10:56effect sizes for particular problems with
10:59focused on ethnic minority populations,
11:02so that the largest effect sizes we
11:04found were for treatment of anxiety
11:06related problems and psychosis.
11:08The smallest effects that we found were
11:11from miscellaneous other problems and
11:13substance use problems essentially,
11:15but again, if you average across.
11:16All of these.
11:19Uh, problem areas.
11:21You get about a medium effect size and then
11:24this is a figure that we just created for a,
11:28a new paper that's impressed at the
11:32annual review of clinical psychology
11:34focus just on cognitive behavioral
11:37treatments and meta analysis that
11:40look at CBT for ethnic minorities
11:43and you find a lot of variations.
11:45So the lowest effect size
11:47was about point O one,
11:49but that's an outlier.
11:52You take that one out and basically you
11:55get effects that are small to very large.
11:59And this is across 13 treatment outcome
12:02meta analysis that we we've done.
12:04So a lot of variation but generally
12:06these meta analysis focus just on
12:09cognitive behavioral treatments suggest
12:11that you get pretty consistent positive
12:14effects for psychotherapies when you're
12:17treating ethnic minority populations.
12:19So it turns out that there are
12:22lots of evidence based treatments
12:24in the literature now focused on
12:27ethnic minorities with a diverse.
12:29Free of mental health problems.
12:32And lots, if you just focus on kids,
12:35that's kind of my my specialty.
12:36So family systems therapies and a
12:39personal psychotherapy, lots of CBT's,
12:42motivational interviewing,
12:43play therapies,
12:44which I was somewhat skeptical
12:45of in my early years.
12:47But if you look at the
12:48treatment outcome literature,
12:49the the data is pretty positive
12:51in terms of plate therapies,
12:52not just for ethnic minorities but
12:55for Euro American kids as well.
12:57What's interesting is that modality
12:59doesn't seem to matter much when
13:01it comes to treatment outcome.
13:02For ethnic minorities.
13:04So some folks have argued that
13:06group based interventions,
13:08family based interventions might
13:10be particularly helpful for ethnic
13:12minorities because it allows you to
13:15intrinsically and implicitly bring the
13:17cultural context into your therapy process.
13:20But but when you look at the randomized
13:23trials that do direct comparisons,
13:25so parent plus child versus child only
13:29family intervention versus individual group.
13:32Treatment versus individual,
13:33you find that for the most part,
13:35it doesn't matter.
13:36The outcomes are similar across
13:38different sorts of modalities,
13:39even those that's implicitly allow you to
13:42bring culture into the treatment context.
13:45OK, so the first question do
13:48treatments work for ethnic minorities?
13:50The answer as well?
13:52Yeah, regardless of how you slice it,
13:55we get pretty good,
13:57pretty reliable,
13:58pretty consistent positive effects
14:00for ethnic minorities.
14:02Not in every single trial,
14:03not not by a long shot.
14:05But if you average across all these trials,
14:07the the the data looks pretty good.
14:10So just because treatments are effective
14:13for ethnic minorities doesn't mean that
14:15they're as effective for minorities
14:16as they are for your American.
14:18So our treatment outcomes worse
14:20for ethnic monitors compared to
14:22Euro Americans. So is there
14:24differential effectiveness so we
14:26we looked at this initially in our
14:292008 review and meta analysis and.
14:33Bill Miller did the same thing with adults.
14:39In in a substance use context.
14:41And both of those reviews found that
14:43for the most part there were no ethnic
14:46differences in treatment effects.
14:48And if you look at other reviews
14:49they find the same thing,
14:51mostly no effects, ethnicity effects.
14:55And then when you do find effects,
14:57a decent number of studies seem to suggest
14:59that ethnic minorities might benefit more.
15:01In fact, we we have a couple of trials
15:03that we've done that suggests this.
15:05So this is an intervention.
15:07We did what we randomly.
15:08Nine, 270 or or so young women at
15:12risk for eating disorders to an online
15:16Internet based dissonance oriented
15:18intervention of Internet based
15:20cognitive behavioral treatment or no
15:22treatment and and the this dissonance
15:24based intervention focus on having
15:26women argue in different ways against
15:28this thin ideal that's prevalent in
15:31Western media and Western social mores.
15:33And what we found is that at post
15:36treatment this distance based on.
15:38Prevention and CBT were more
15:40effective than no treatment,
15:41reducing symptoms and and
15:43body dissatisfaction.
15:44No surprise there.
15:45But more important for this talk
15:47we found that ethnic minorities
15:49benefited more than you're Americans
15:51from the active intervention in
15:54terms of lower eating pathology,
15:56less depression and and we found no
15:58effects for for white participants.
16:01So why is this?
16:02Well we we don't know for sure,
16:04but we we did speculate.
16:07And by the way we didn't expect this.
16:09We we sort of speculated post hoc
16:12that given that this ethnic minority
16:15sample was really predominantly
16:17Asian Asian American students,
16:19Asian American women,
16:21and previous research found that East
16:24Asian women tend to prefer a lower
16:26body weight and and that they tend
16:28to be more critical of their bodies
16:30than than you are American women.
16:32What we argued that it's possible
16:35that the Asian women experience
16:38more psychological discomfort.
16:40Then then whites when when prompted
16:42to argue against this, then ideal.
16:44And that may have resulted in
16:47greater dissonance which we were
16:49trying to evoke and therefore a
16:51superior intervention response.
16:53So,
16:53but my larger point is that sometimes
16:56when you do find differences,
16:59sometimes they seem to favor Euro Americans,
17:02but other times they favor.
17:05I think minorities and we looked at
17:07this in a bigger way in this sort
17:10of ongoing review of meta analysis,
17:13so kind of like a mega analysis
17:15we're we're synthesizing other
17:17meta analysis that have been done,
17:19a former student are doing that.
17:21And what what we found across these
17:2329 meta analysis that look at
17:25ethnicity effects is that we find the
17:27same general pattern generally no
17:30ethnicity effects about 62% showed
17:32no effects about 14% of these men analysis.
17:36So that whites benefit more,
17:37but then about 17%,
17:39so that ethnic minorities benefit more.
17:42And so overall there,
17:44there the evidence suggests that there
17:47are no consistent ethnicity effects.
17:50When you're looking at, say,
17:52ethnicity as a moderator of
17:54treatment effects,
17:55mostly minorities and Euro
17:58Americans benefit equally.
18:00Sometimes there are differences,
18:01but when there are differences,
18:03it seems that ethnic minorities.
18:05Are just as likely to benefit
18:08more than than you're Americans.
18:10OK, so interventions,
18:13treatment cycle therapy seemed to
18:17work well with ethnic minorities.
18:19They seem to work equally
18:21well in many of these trials,
18:23and certainly in the research
18:26syntheses that that suggested.
18:28But that doesn't quite get at whether
18:31cultural tailoring is important or not.
18:34It could be that.
18:35One reason that these interventions work
18:37as well as they do for ethnic minorities
18:39is because there's a lot of tweaking,
18:41modifying, adaptation,
18:42cultural enhancement going on within
18:44the context of these interventions.
18:47So it's still relevant and important
18:48to to try to answer whether tailoring
18:51enhances outcomes for ethnic minorities,
18:53and there are lots of reasons to.
18:55To think or believe that culture
18:59might be important and.
19:01The the clinical context and and my
19:04students and I have done a lot of work
19:06on this issue over the past decade.
19:09We had more time I talked about
19:10some of the work that we've done
19:12looking experimental work we've
19:13done looking at stigma.
19:14But but there's a lot of data out there
19:17suggesting that ethnic minorities in
19:18our cultural context in the United
19:20States tend to see having a mental
19:22health problem as more stigmatizing
19:24than you're Americans and and
19:26seeking out treatment for seeking out
19:29professional treatments being more more.
19:31Stigmatizing.
19:34Ethnic minorities in general are are
19:36less likely to seek out professional
19:38help for their mental health problems.
19:40Are are mixed data in terms of the
19:43extent to which they underutilize.
19:46Mental health services.
19:47Some data, for example, example,
19:49suggesting that African Americans tend
19:51to underutilize outpatient services,
19:54but in some ways overutilized
19:57inpatient services.
19:58So kind of a mixed picture there.
19:59But but areas of ethnic disparity and
20:02and why you might think that culture
20:05would be a salient factor to consider.
20:09We've looked down a decent amount of
20:12literature of done a decent amount,
20:14done a decent amount of work looking
20:17at mental health correlates that might
20:19be specific to ethnic minorities.
20:21And immigrants.
20:23So this slide just shows some of
20:25the the the work that we've done
20:28including a meta analysis that we just
20:31did recently looking at something
20:33called the immigrant paradox.
20:35So how how immigrants have more
20:38immigration related stressors but
20:40they also seem to have fewer mental
20:43health problems than than native born
20:46folks have the same broad cultural
20:49background. Lots of data suggesting.
20:51That certain cultural groups drop
20:54out of treatment at higher rates
20:56than you're Americans.
20:58And then there's data suggesting
20:59that ethnic minorities generally,
21:01but Latinos, Native Americans,
21:04and African Americans more more specifically,
21:07tend to face greater treatment.
21:09Barriers are relative.
21:11To to Euro Americans.
21:14So lots of reasons to think that
21:16culture might be important to consider.
21:18So what is culture responsive treatment?
21:20Well,
21:20there's there's no one uniform view here.
21:23A lot.
21:24Lots of frameworks,
21:24lots of theories,
21:25lots of perspective,
21:26lots of opinions and and
21:28lots of labels that that
21:30are out there too.
21:32So my, my broadly I'm,
21:34I'm sort of operationalizing a culturally
21:38responsive treatment as any effort
21:40to make treatments more appropriate.
21:42For ethnic minority populations.
21:47Lots of models out there.
21:48I just have a few here, Larry,
21:51Roger ahead in early model,
21:54kind of the tripartite model.
21:56Guillermo bernal.
22:00Steve Lopez, one of my colleagues
22:02at USC has this really cool
22:05shifting cultural lenses model.
22:07So and then in a.
22:10In a few review papers,
22:12we we basically argue that there
22:15are three broad ways of thinking
22:17about cultural competence.
22:19If you look at the broader
22:21theoretical literature.
22:22So their skills models these
22:25prioritize developing it and applying
22:27clinician culture knowledge to the.
22:30Therapeutic enterprise,
22:31and this is generally what we think about
22:34when we think of cultural competence,
22:36cultural competence sort
22:37of training for clinicians.
22:39And then there are the adaptation models
22:42and this tends to prioritize tweaking,
22:44adapting or modifying a a treatment,
22:49particularly a manualized treatment.
22:51And then these process models
22:53and the this focuses more on like
22:57therapeutic interactions trying
22:58to elicit cultural meanings.
23:00And then using that that understanding
23:03of those meanings to shape treatment
23:07goals and strategies and ways to match
23:11the the worldviews of the client.
23:15And it turns out that the skills
23:19models and the process models that
23:22that there there's the least amount of
23:25rigorous data supporting these and a
23:27lot of the empirical action has been with.
23:30Cultural adaptation.
23:31So even though a lot of theories focus
23:35on skills based models that try to
23:38that argue for cultural competence training,
23:41there's very little data rigorous
23:43data looking at that and instead
23:46the the evidence base tends to
23:48focus more on adaptation models.
23:50So if you look at some broad
23:55recommendations that are are made with
23:59regard to treating ethnic minorities,
24:00so some.
24:01And minority recommendations are
24:02to use short term time limited,
24:05pragmatic,
24:05directive goal oriented treatments
24:07with ethnic minorities being
24:09intended to the effects of ethnic
24:12minority status or discrimination,
24:13trying to validate the clients
24:15experiences with racism,
24:16role induction,
24:17basically orienting clients to to to therapy.
24:21The assumption being,
24:22and it's a valid assumption that
24:25ethnic minority center has have
24:27less experience with therapy,
24:29they they tend to be less
24:30familiar with the culture.
24:31Of therapy, basically.
24:33And then, Umm,
24:34cultural or ethnic match.
24:38Now the the problem is that there's
24:40not a lot good evidence based
24:41for most of these ethnic matches.
24:43One example,
24:43if we have time we can talk more about that.
24:45That literature role induction
24:47is an exception.
24:48There is some actually good data
24:50suggesting that that might be particularly
24:52helpful with ethnic minorities.
24:54And then in terms of specific groups,
24:56again these are these are broad
24:58recommendations and I'm not necessarily
25:00endorsing these incorporated.
25:01Spirituality and face based coping
25:04selected use of African American
25:06Vernacular English or or Black English,
25:09with the caveat that if you're
25:11not a native speaker yourself,
25:12as a clinician you might be.
25:16Maybe not want to to use black
25:19English for Asian Americans or
25:21or folks of East Asian descent.
25:23Accepting and tolerating
25:24low levels of expressivity,
25:26avoiding comments construed as
25:28critical of disproving for Latinos,
25:31involving the family,
25:31and treatment using the polite
25:33form of you or who stead when
25:34you're working with adults.
25:35So. So again,
25:37these are just a sampling of the large,
25:40just set of recommendations that
25:42are made by experts out there, OK?
25:44So let's let's that that
25:46that was the context.
25:47Now let's get to the evidence.
25:49It turns out that if you look
25:51at the current literature,
25:52research has been published
25:54over the past 20 years or so.
25:57Most ethnic minority focused treatments
25:59in the context of randomized trials
26:02are culturally tailored in some way,
26:04one way or another.
26:06So that's increasingly the norm.
26:08My dog is barking.
26:10I need to let her out.
26:12Give me 30 seconds.
26:13Sorry.
26:40Ethnic minority focus. Totally tailor.
26:46So we in our 2014 paper,
26:52we basically synthesized 10
26:54meta analysis that looked at the
26:57effectiveness of culturally tailored
27:01interventions for ethnic minorities.
27:03And all of them all.
27:04Ten of them showed that culturally tailored
27:06treatment was better than no treatment,
27:08placebo, and treatment as usual.
27:11But but that doesn't quite
27:12answer the question of whether
27:13culture tailored treatment.
27:15Much better than generic treatment
27:18standard treatments that don't
27:20necessarily consider the cultural
27:22mores of the client population.
27:27So when we look more specifically
27:30at the adapted tweet tailored
27:34treatment versus generic,
27:37you know our own lab,
27:38we find these really mixed results
27:40and I'll just give you 2 examples
27:42of two meta analysis that that take
27:44you in two different directions.
27:46So this is the one that we published
27:50in 2008 and we looked at culturally
27:53responsiveness in two different ways.
27:55We we it was a more conservative.
27:57Definition where if in the
27:58context of the randomized,
28:00published,
28:00randomized trial they mentioned tweaking,
28:02adapting, or something like that,
28:04then it was culturally responsive.
28:06But we also used a more liberal definition.
28:08We went to treatment manuals,
28:10we went to chapters,
28:11we we got some other info from
28:14from the treatment developers,
28:16and if they if there was any info
28:19suggesting in those secondary sources that
28:22the intervention was closely responsive,
28:24then we we defined it a more liberal way.
28:27Either way you slice slice it,
28:29conservative versus liberal definition
28:31standard and culture responsive
28:33interventions were equally effective
28:35in our meta analysis for kids.
28:37But then in our meta analysis
28:40focused on Asian Americans,
28:42specifically East Asian
28:44Americans and SE Asians,
28:46we found this interesting gradient
28:49where those interventions tailored
28:52specifically for East Asian
28:54subgroups like Chinese Americans.
28:56Korean Americans had the most robust
28:59effects and then those tailored
29:01broadly for Asian Americans had
29:02kind of a more moderate effect.
29:04And those tailored broadly for
29:06minorities are not tailored.
29:08All had the lowest or smallest effects.
29:10So in our own work,
29:13what we're finding kind of these
29:15sort of different possibilities,
29:17different findings in terms of.
29:20Cultural tailoring effects.
29:21And then the most rigorous way to look
29:25at this is to look at those studies
29:27that specifically compare a generic
29:30intervention to a culturally modified
29:32version of the same intervention.
29:35So a culturally adapted CBT
29:38versus a generic CBT.
29:40We found about ten of
29:42those about a decade ago,
29:44and we synthesized them in a meta analysis,
29:47and we found an effect size of.
29:500 zilch.
29:51In other words,
29:53the culturally tailored interventions
29:54were no more effective than the
29:57generic interventions in these
29:59head-to-head comparisons now.
30:01So keep this in mind because we're going
30:03to come back to this briefly shortly.
30:05So what do we know so far?
30:08Therapies are generally
30:09effective for ethnic minorities,
30:11and this is true in lab
30:13and real-world settings.
30:14Now,
30:15it turns out that in real world settings
30:17the the effects tend to diminish,
30:19but that's true for euro.
30:21As well,
30:22many evidence based treatments
30:23are are out there,
30:25although they've been developed primarily
30:28for for Black and Latinx folks.
30:30But the the data is growing when
30:33it comes to Asian Americans,
30:35indigenous populations,
30:36and ethnic minorities in other countries.
30:40In fact, we're working on a meta
30:41analysis now focused on indigenous
30:43populations not just in the US,
30:44but also where they're mostly CBT's,
30:47but not exclusively.
30:48We also find that ethnic minorities in your.
30:50America's mostly benefit equally and
30:53overall cultural tailoring doesn't appear
30:56to reliably enhance treatment effects.
30:59So does culture matter and this
31:04does cultural tailoring matter?
31:06I think the answer is yes,
31:07but like like many things in life,
31:10it's it's complicated.
31:11So I'm going to quickly go through
31:15like 5 lessons that I've kind
31:17of learned in immersing myself
31:18in this literature and doing.
31:21This this work over the past
31:2320 years or so first.
31:26I would argue that successful,
31:28culturally responsive treatments
31:30might be redundant with what many
31:33clinicians do naturally anyway.
31:36So this is a figure taken from our
31:38our 2014 paper and it basically shows
31:41the percentage of clinicians based
31:44on self report who say that they're
31:47fairly competent when working with
31:49ethnic minorities or that they tweak,
31:52adapt or modify in some way to
31:53to make their interventions more
31:55relevant for ethnic minorities.
31:57And it turns out that the the
32:00overwhelming majority of clinicians
32:01say that they're competent and
32:03or that they that they tweet.
32:05Or adapt or or modify in some way.
32:09So adaptation, tweaking,
32:10being sensitive at least based
32:12on self report from clinicians
32:15is is essentially the norm.
32:17Now.
32:17It doesn't mean that they're doing it well.
32:19My my suspicion is that
32:21there's a lot of variation,
32:22like some some some are really,
32:24really good at it and they get great outcomes
32:27when they adapt and others are horrible.
32:30But but it it is the norm.
32:32So that's some one thing
32:34to sort of keep in mind.
32:36Another is this notion of equifinality
32:38and and and it it it the argument
32:42here is that culturally diverse
32:44clients might take different paths
32:47within the same intervention
32:49to arrive at the same place.
32:52So you can give different
32:55groups the same intervention.
32:57The processes what happens in treatment
32:59might look somewhat different,
33:01but they they get to the same
33:03place essentially.
33:04So,
33:04so one of the problems here is that
33:06there's not a lot of research looking
33:08at ethnocultural differences and
33:09treatment processes and and that's
33:11what we did in this particular
33:12study by one of my former students.
33:15So,
33:15so there's this notion that resistance
33:18in the context of treatment is,
33:20is bad generally.
33:21And Patterson and Chamberlain and
33:24other scholars have kind of start to
33:26normalize that and argued that well
33:28resistance is actually kind of kind of OK,
33:31it's it's sort of normal and they they
33:32have the struggling working through
33:34model that they develop basically
33:36saying well you expect resistance to
33:37be low at the beginning of treatment
33:39and low at the end of treatment,
33:41but you expect a decent amount of it
33:42in the beginning and that's that's
33:44maybe a good thing because this
33:46suggests that they're struggling
33:48and working through as clients to
33:50get to a better a better place.
33:52So, so therapist should anticipate.
33:54This and work with this,
33:55but not just think of it as a bad thing.
33:57And what they find in their work is
34:00that with predominantly white families
34:02in parent training is that this
34:04struggle in working through pattern
34:06is predictive of better outcomes.
34:08So we wanted to see what this
34:11applied to black families who are
34:14getting multisystemic therapy.
34:16And these were mostly black and white
34:20kids in the juvenile justice system
34:22who also had comorbid substance use.
34:24Problems and what we found was that
34:28the struggle and working through
34:31pattern was true and and held
34:34for your American families.
34:36Yes, they they showed this same pattern
34:38that Chamberlain and Patterson argued for,
34:40but African American families
34:41showed a different pattern.
34:43They they struggled around the same
34:45amount at the beginning of treatment,
34:47in the end of treatment,
34:48but they struggled a lot less than Euro
34:50Americans did in the middle of treatment
34:52during that kind of working through.
34:54Process.
34:56So and I won't get into
34:58this complicated figure.
35:00So it it argues that.
35:02So that data suggested that our black
35:05families and our white families getting
35:08the same interventions had this sort
35:10of different resistance trajectory
35:13within the context of treatment,
35:15but they got to the same place
35:18outcomes were similar for our
35:20black and white families.
35:22Another lesson is that cultural
35:24responsive treatment effects
35:25might vary by acculturation,
35:27status,
35:27and here I'll focus on a trial that we.
35:32Did a decade ago where we randomly
35:36assigned phobic Asian Americans to either
35:39get a standard exposure based treatment,
35:42a culturally modified version
35:44of the same treatment,
35:45or a self help intervention.
35:47And these are mostly small animal phobics
35:51and and I won't get into the adaptations,
35:55but there are 7 broad adaptations that
35:57we made to this this intervention.
36:00Many of them had spider phobias,
36:02but not all of them.
36:03And basically what what we found
36:05is that the culture we adapted
36:08intervention and the standard
36:10intervention were both fairly effective
36:12relative to the control condition
36:14at getting good outcomes at post
36:17treatment and then six months later.
36:20But more interestingly and also the
36:24adaptive intervention was somewhat more
36:27effective for two of the outcomes.
36:30Then then the standard intervention.
36:34But then,
36:34when we looked at a culturation stage,
36:36we found some interesting patterns.
36:37So the culture adapted into
36:40intervention seemed to work
36:42best for those who are most.
36:44Identify with their Asian American heritage.
36:48So the the low acculturation or the the
36:51high Asian identified folks seem to
36:55have the best response to our culture.
36:57We adapted intervention and there are
36:59a couple of other trials done by other
37:02scholars that find something similar.
37:03So you don't find this all the time,
37:05but you find it enough to
37:07suggest that there might
37:09be a pattern. Another interesting finding
37:13is that cultural responsiveness can help.
37:17In some cases, and it can harm in others.
37:20Recall that meta analysis that I
37:22mentioned where we got an overall effect
37:24size of point O1, essentially zilch,
37:26where the we looked at studies that
37:30compared adapted interventions to
37:32generic versions of the same treatment.
37:36So yes, the overall effect was .01,
37:38but if you look at the individual trial
37:41outcomes, you see a lot of variation.
37:43Some of the trials show pretty
37:45robust positive effects,
37:47other trials showed pretty
37:49robust negative effects.
37:50So the argument is that tailoring
37:52can be helpful in some cases,
37:54but it can harm in other cases.
37:56So, well, why is this?
37:57Well, it turns out that some scholars have
38:01have speculated on why this might happen.
38:03Monica Webb argued that, well,
38:05sometimes some forms of cultural
38:09adaptation might evoke negative
38:11emotional reactions in in.
38:15Ethnic minority clients.
38:16So for example,
38:17she had a this smoking cessation
38:20intervention that was culturally
38:22adapted where they had sort of slavery
38:24imagery that they used to kind of
38:27highlight some of the negative effects
38:29of smoking for African Americans and
38:31and that that their sense is that when
38:35they reflect on later that it may have
38:38rubbed some of their African American.
38:41Clients the wrong way basically.
38:45Another argument,
38:46I think this is maybe a more
38:47important argument,
38:48is that there might be less
38:50activation of change mechanisms if
38:52you focus too much on the cultural
38:54content or cultural context.
38:56So.
38:56So tailoring in this way it might
38:59distract from core intervention
39:00strategies or create inefficiencies
39:02in in your your intervention in ways
39:06that might interfere with the active
39:09ingredients of of the the intervention.
39:11Wendy Clara did this interesting study
39:13that kind of looked at this, but we're.
39:15Let me I need to flip past that and
39:18and go through a couple more slides
39:21so we have enough time for Q&amp;A.
39:24So culture responsive interventions can help.
39:27Sometimes they can harm and other times.
39:30And in fact 5th my 5th lesson is
39:33that effective culture we talked of
39:36treatment might challenge conventional
39:38notions about what matters when.
39:41We're addressing diversity.
39:45So Brian Kim, counseling psychologist,
39:49did a series of really cool analog studies
39:55evaluating Epic match with Asian Americans,
40:00and they found that Asian
40:03American counselors,
40:04when paired with Asian American clients,
40:09smiled less than Euro American counselors.
40:12An Asian American counselors
40:15received lower session positivity
40:17and session arousal ratings,
40:19then Euro American counselor.
40:21So again,
40:22all Asian American clinicians.
40:26But the Asian American counselors
40:29are smiling less,
40:30and they're perceived less positively
40:34than Euro American counselors.
40:36So this leads to this very
40:38counterintuitive possibility.
40:40It's just suggests that sometimes.
40:42Ethnic minority therapists,
40:44particularly those who might
40:45be more culturally attuned,
40:47might inadvertently engage in less therapy
40:50conducive behavior than white therapist.
40:52And this might have,
40:54you know, implications for,
40:56you know,
40:57the this interesting ethnic match literature.
41:04One of my increasingly favored studies is on
41:08done by Immel and his colleagues and the.
41:15The the premise here is that we
41:17really don't know what reliably
41:19makes some therapist more effective
41:22with ethnic minorities than others.
41:24But what we do know is that some
41:27therapists are reliably more
41:29effective with ethnic minorities.
41:32Than than others and Emma's
41:34work kind of highlights this.
41:36So and that there were kind of suggests this,
41:40this possibility for reverse engineering
41:42the cultural competence process.
41:45So, so his group basically reported data
41:47from a large clinical trial showing
41:50that although outcomes generally
41:52were equivalent for white and ethnic
41:55minority folks in drug treatment,
41:57some therapists had great outcomes.
42:01The clients broadly?
42:03Umm. And and importantly,
42:06some therapists had superior outcomes
42:08with white clients whereas some had
42:11better outcomes with ethnic minorities.
42:13So some therapists appeared to be more
42:15skilled at treating minorities where
42:17others are more skilled than treating whites.
42:19But but more importantly,
42:21some therapists appeared to be great at
42:24treating everyone white and minority.
42:26So basically the lower the value here
42:29the the the better the the outcome.
42:32So so these are.
42:35Are star clinicians basically who
42:38are who are reliably getting good
42:40outcomes not just with white clients,
42:43but with ethnic minority clients too?
42:46So they're getting good outcomes
42:48generally and they're getting it those
42:51outcomes for white and minority clients.
42:54So these are the folks we want to emulate
42:56and we want to find out more about.
42:58Um,
42:58however these clinicians are overall
43:01they're not getting great outcomes
43:03and you're seeing the disparity.
43:05So their outcomes for epic minorities are
43:09worse than they are for Euro Americans.
43:14So the so in and more studies have been
43:18done replicating kind of this finding.
43:21So therapist variability in terms of
43:23your ability to get good outcomes broadly
43:26and your ability to get good outcomes.
43:29For ethnic minorities in
43:32relation to Euro Americans,
43:34but what we don't know is what it is
43:37that these star clinicians are doing
43:40compared to these clinicians who need
43:43kind of maybe maybe more help in terms of,
43:45you know,
43:48reducing disparities.
43:50So what Emmel argues is that,
43:52well,
43:53maybe culturally competent therapists are
43:55those who achieve equivalent outcomes
43:57with white and minority clients,
44:00but they're also meeting some sort of
44:03absolute standard of of effectiveness.
44:08OK, let me just give some quick reference
44:11recommendations and I'll kind of wrap it up.
44:13So given all this context,
44:15given everything I've thrown at,
44:16what, what, what am I recommend?
44:19In the past I was kind of reluctant
44:20to give concrete recommendations,
44:22especially when it came to cultural
44:24competence as you since the research is
44:25is still kind of shaky at this point,
44:27but I think I feel more confident now,
44:30especially given some of the new
44:32stuff that's that's come through
44:34the pipeline over the past decade.
44:37So what I recommend a cognitive behavioral
44:39therapy is another evidence based
44:40treatments as first line treatments,
44:42continuous assessment and feedback.
44:44What we do know is that when clinicians
44:47are monitored and when they get feedback
44:51session by session from clients,
44:53that feedback seems to improve
44:55performance and you find this in for
44:57clients more broadly and for ethnic
45:00minority clients more specifically.
45:04There, there. It turns out that their
45:07engagement strategies that seem to
45:09work well for your Americans and ethnic
45:11minorities appointment prompts work well.
45:14Role induction, orienting clients
45:16at in those first initial sessions
45:19to the the culture of treatment,
45:21actively addressing treatment
45:22barriers early on in treatment.
45:24These things seem to work fairly
45:26well regardless of ethnic background.
45:29And then what about tailoring?
45:30What are some ways?
45:33To to think about tailoring,
45:35you can use evidence based treatments
45:37that include tailored elements,
45:39adopting a tailoring model with a
45:45method that individualizes to address
45:47code for factor, so acceptance and.
45:51A commitment treatments
45:53multisystemic therapy,
45:55which I did for a number of years.
45:58The Incredible years program for
46:01kids with behavioral problems,
46:02and this is just a sampling of
46:05interventions that have this sort of
46:07individualized approach that intrinsically
46:09kind of addresses cultural factors.
46:12This is one of the many tailoring
46:14models that are out there,
46:15but be mindful of the possibility
46:18that doing too much tailoring
46:20or tweaking or modifying can
46:22interfere with active ingredients.
46:24So so you do the tailoring
46:29and cultural infusion.
46:33In moderation and and with that
46:37possibility that that concern in mind
46:40and then and then finally a approaching
46:43tailoring as hypothesis testing,
46:44not as an assumption there.
46:47There's a lot of variability
46:50across our diverse clients.
46:52So we probably shouldn't go in assuming
46:54that we need to tweak Taylor adapt
46:57or modify in some way just because
46:59someone's African American just
47:02because someones Central American.
47:04Heritage and just approaches hypothesis
47:07testing and assess routinely as
47:10you're doing your intervention.
47:13Umm. Well, let me stop there.
47:18OK,
47:19stop share.
47:19And I think we have maybe about
47:2210 minutes for questions.