Yale Psychiatry Grand Rounds: September 23, 2022

Transcript

• 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&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.