Cultural Adaptations to Psychotherapy

Cultural Adaptation Approaches

In our review of the impressive work being done to deliver culturally relevant treatment to ethnic minority communities, we realized that some authors, such as Binkley and Koslofsky and Cheng and Merrick, are using Evidenced Based Treatments and then making needed changes to culturally adapt their interventions, while others, such as Benson-Flórez, Santiago-Rivera and Nagy, Cumba-Avilés, Kohrt, Lincoln, and Brambila, and Maríñez-Lora and Cruz are using theories and techniques that are already working with ethnic minority communities and then making cultural adaptations as needed for their specific clients.

Most of the articles used a specific cultural adaptation model in their treatment. Binkley and Koslofsky and Maríñez-Lora and Cruz used the ecological validity framework model (Bernal, Bonilla, & Bellido, 1995), while Cheng and Merrick used Hwang’s (2006, 2012) top-down and bottom-up approaches, developed specifically for use with the Asian Americans. Benson-Flórez and colleagues and Cumba-Avilés used a treatment that had already been culturally adapted using the ecological validity framework and made further adaptations based on their clients’ needs. For a list of cultural adaptation models, see Domenech Rodríguez and Bernal (2012b).

Not all authors used a specific model; however, their adaptations mapped on to existing recommendations. Notably, Kohrt and colleagues made cultural adaptations that represented shifts in language, persons, metaphors, content, concepts, goals, methods, and context, the eight dimensions of the ecological validity framework. Specifically, the authors addressed hozho and a connection to nature as part of treatment shifting content to reflect a more appropriate fit to their Native client. Kohrt et al. integrated nature as part of diaphragmatic breathing and the client practiced aligning her breathing with the movement of the trees in the wind. They addressed concepts such as lifeworld and intergenerational context as part of case conceptualization. Integrating the client’s mother into treatment and consulting with a tribal healer represented shifts in methods.

Reconceptualization of Existing Tools

A striking observation in our review of these articles is the fact that much of the cultural adaptations result from psychotherapists’ masterfully marshaling existing resources in evidence-based practice in the service of engaging culturally diverse clients. For example, two of the articles discuss the use of genograms. Binkley and Koslofsky use the genogram as a strategy to gather the cultural story and make treatment more family-oriented and consistent with the cultural value of familismo. Kohrt et al. use the genogram to gather important family information and demonstrate an understanding of the client in their American Indian/Alaska Native cultural and collectivist context. These were compelling examples of cultural competence being built upon clinical competencies as genograms have long been a powerful tool in treatment approaches in family therapy (McGoldrick, 2011); however, they are not readily found in pre-packaged evidence-based interventions.

Similarly, psychotherapists used general clinical tools in the service of culturally specific values, beliefs, and practices and also culturally specific realities. For example, Kohrt and colleagues used diaphragmatic breathing and conceptualized the breaths as the vehicle to help the client feel more connected to nature. Cheng and Merrick actively engaged their client’s family to help them understand depression and eating disorder symptoms while actively navigating cultural differences in beliefs regarding eating, nutrition, and family roles in these. Benson-Flórez et al. developed a safety plan with their family in the event of deportation, thus directly addressing the threating and real sociopolitical context that is unique to Latino clients. Finally, Binkley and Koslofsky and Kohrt, Lincoln, and Brambila discussed the need for ongoing risk management in light of client’s self-harm, recent suicide attempt, and homicidal thoughts.

Strategies such as genograms, diaphragmatic breathing, safety plans, and risk assessment are part of the standard clinical practice of psychotherapists. The use of these strategies in culturally adapted work reminds us that cultural competence does not necessarily require learning a new set of strategies. Rather, cultural competence may often be the willingness to deploy clinical competence to actively address the client’s culture in clinically meaningful ways.

In addition to clinical strategies or techniques, psychotherapists also discussed basic structural changes needed to meet the needs of their client. Benson-Flórez and colleagues as well as Maríñez-Lora and Cruz discuss changes in session frequency, location, time, and even treatment dosage, which responded to clients’ contextual needs. Cheng and Merrick discuss the intermittent integration of their client’s parents into session based on their visit schedule. Finally, Cumba-Avilés described a session between sessions to meet with a client and his family due to reports of suicidality.

Intersectionality

Psychologists and psychotherapists have increasingly turned their attention to intersections of identity that amplify or reduce risks of negative outcomes (Domenech Rodríguez, Donovick, & Straits, 2015). The authors in this volume address intersectionality head on. Cheng and Merrick discuss the ways in which their client’s female gender plays a role in her case conceptualization, while Cumba-Avilés explains how treatment is influenced by the co-morbidity of disorders as well as the ages of the clients. Finally, Binkley and Koslofsky use a specific model that considers the role of societal, family, and childhood factors in ethnic minority child development. Their article also addressed the role of therapist identities on the therapeutic relationship. The fact that multiple authors addressed their own intersectionalities and how these possibly affected treatment reflects cultural humility (Tervalon & Murray-García, 1998) that is so central to pursuing cultural competence. It is at the intersections of identities that already culturally adapted evidence-based interventions needed further “tweaking” by our authors.

Dynamic and Ongoing Cultural Adaptations

All of our authors clearly document the dynamic nature of cultural adaptations. Psychologists must use their clinical skills to make changes as needed throughout treatment. At the outset of treatment, Maríñez-Lora and Cruz respected their client’s autonomy to remain in her romantic relationship, which was marked by serious interpersonal violence, and worked with the client to target important therapeutic outcomes of importance to her, which targeted traditional cultural roles. For some cases, mid-treatment clinical emergencies such as suicidality, homicidality, and cutting behaviors necessitated pauses in structured treatment to focus on risk assessment and management (Binkley & Koslofsky, 2016; Cumba-Avilés, 2016; Kohrt et al., 2016). Also, there were instances when treatment needed to focus on problem solving with clients to support their ability to meet treatment goals (Benson-Flórez et al., 2016).

Cultural adaptations occur throughout all parts of treatment; intake, assessment, and intervention. A notable challenge across articles was locating relevant instruments that were normed with culturally diverse populations, or even clinical tools to capture cultural constructs. Our authors were thoughtful in their selection of instruments and in their interpretation of findings providing an excellent model for clinicians and researchers alike.

In all, the articles in this volume suggest that psychotherapists are doing excellent work in the field, integrating their knowledge regarding cultural adaptations, and deploying it flexibly in the service of meeting clients’ treatment goals while considering their clients’ culture and the many intersections of their identities. Psychotherapists in this volume consult with colleagues, families in treatment, and the existing literature to address important treatment considerations, explicitly modeling how to be scientist-practitioners and practitioner-scholars.

These skilled psychotherapists show how they practice in ways that demonstrate cultural competence and cultural humility. And although we do not purport to have a definitive answer to the question “how do I culturally adapt my treatment to my specific client at this specific time?” we can certainly reflect on the importance of continuing the journey as lifelong learners by cultivating knowledge (e.g., reading recently published literature) as well as self-awareness (e.g., intersectionality) and specific skills (e.g., genogram, cultural conceptualizations). Cultural adaptation models ultimately were developed by skilled clinicians who wanted guidance for their clinical practice or clinical research activities. When analyzed together, cultural adaptation models appear to have many overlapping similarities (Domenech Rodríguez & Bernal, 2012b); thus, it is no coincidence that even authors who were not using published models landed on adaptations that were an excellent reflection of existing models.

It is our hope that this volume opens a long and nuanced conversation about the many ways in which evidence-based treatments are culturally adapted, in the real world, to meet clients’ needs. It is in these everyday actions that psychotherapists engage social justice and address the many injustices that have led to dramatic health disparities in ethnic minority communities. We hope this volume strengthens their resolve and inspires others to engage these powerful daily social revolutions.