Cultural Adaptations: A Complex Interplay between Clinical and Cultural Issues

Abstract

Psychotherapy is a Western method of treating mental illness. Culturally adapting psychotherapy to better meet the needs of ethnic minorities is an important endeavor. Hall et al. (2011) did an excellent job of reviewing the intersection and divergence between Asian culture and mindfulness and acceptance-based therapies. They also point out that some therapies can be naturally syntonic with Asian American cultural values and belief systems. This is especially important given cultural differences between the East and West. Below, I provide an overview of the complexities involved in adapting treatments for diverse clients. I also discuss the importance of deconstructing stereotypes and understanding the complex interplay between clinical and cultural issues. Individualization of treatment for diverse clients can be achieved through culturally formed practice.

The importance of culturally modifying and adapting psychotherapy to meet the needs of ethnic minorities is an important new "hot topic." Improving the effectiveness of mental health treatments for people of non-European backgrounds is especially important given that three-fourths of the world is collectivistic and possess belief systems that are distinctly different than the Western world. It is known that ethnic minorities are less likely to receive quality health and mental health services, and that overall they evidence worse treatment outcomes than European Americans (IOM, 1999; USDHHS, 2001).

Although there is debate about whether an "as is" approach to implementing evidence-based treatments (EBTs) is sufficient in treating ethnic minorities, it would be difficult to argue that culturally modifying and individualizing treatments for minority clients would not improve therapeutic outcomes. This cultural adaptation and individualization of treatments already occurs for Europeans and European Americans, which therapy was designed for. Specifically, the paradigm of psychotherapy was developed in the West, and psychotherapy is heavily laden with Western cultural values and beliefs.

This is not to say that an “as is” approach to psychotherapy will not work with ethnic minorities. Certainly an “as is” approach to implementing EBTs is likely to generalize to some groups and provide some therapeutic benefit. The real question is whether targeted cultural adaptations can further improve treatment outcomes, increase client engagement, and reduce premature treatment failure. Many clinical scholars who focus on reducing international and domestic mental health disparities believe that this is an important endeavor. Clinical researchers have already begun culturally adapting Western psychotherapy to better meet the needs of diverse communities. In addition, there is also some evidence that culturally adapted treatments, and even simplistic cultural adaptations to mental health interventions, such as language and ethnic match, can benefit minority clients (see meta-analysis by Griner and Smith, 2006).

Resnicow (1999) discusses two types of cultural sensitivity that can help improve treatment for ethnic minorities. Surface structure includes more superficial adaptations, such as conducting therapy in a client’s native language, providing ethnically matched therapists, designing the clinics to be culturally aesthetic and locating clinics in neighborhoods that are easily accessible. In contrast, deep structure involves incorporating the ideas, beliefs, and values into the treatment. This type of adaptation is much harder to develop, but has the potential for increasing cultural congruence between psychotherapy and the client’s background, consequently improving treatment acceptability and outcomes. Although there has been a lot of research conducted on surface structure adaptations (e.g., ethnic and language match studies), research on deep structure adaptations has been quite limited.

Few comprehensive frameworks for implementing deep structure adaptations, which require more intensive changing greater thoughtfulness, are available. Bernal, Bonilla, and Bellido (1995) came up with one of the first frameworks, focusing on 8 different dimensions including language, persons, metaphors, content, file concepts, goals, methods, and context when adapting therapy for culturally diverse clientele. Hwang (2009; 2011) developed two integrative frameworks for adapting therapy. The Formative Method for Adapting Psychotherapy Framework (FMAP) is a community-based and bottom-up approach for culturally adapting psychotherapy. The FMAP approach consists of five phases: (a) generating knowledge and collaborating with stakeholders (b) integrating generated information with theory and empirical and clinical knowledge, (c) reviewing the initial culturally adapted clinical intervention with stakeholders and revising the culturally adapted intervention, (d) testing the culturally adapted intervention, and (e) finalizing the culturally adapted intervention.

In the second phase, the FMAP integrates the more theoretically driven and top-down Psychotherapy Adaptation Modification Framework (PAMF), which consists of 6 therapeutic domains and 25 therapeutic principles (Hwang, 2006). The domains include: (a) dynamic issues and cultural complexities, (b) orienting clients to psychotherapy and increasing mental health awareness, (c) understanding cultural beliefs about mental illness, its causes, and what constitutes appropriate treatment, (d) improving the client-therapist relationship, (e) understanding cultural differences in the expression and communication of distress, and (f) addressing cultural issues specific to the population. Although the PAMF is a more general framework for adapting therapy and improving cultural competency, the FMAP was created to facilitate development of culturally adapted EBTs.

Falicov (2009) pointed out that “cultural attunements” may help synchronize treatment to better match ethnic cultures and the social contexts in which clients live. Hall et al.’s (2011) paper is unique because it not only discusses culturally adapting EBTs, but also points out that some treatments may already be more culturally attuned or syntonic with some cultures than others. Hall et al.’s (2011) choice of utilizing a treatment that is already highly culturally attuned can help reduce the number of modifications needed. Although many randomized controlled trials (RCTs) testing different types of therapy have been conducted with European Americans, no well conducted RCTs testing different types of therapies have been done with ethnic minority groups. Treatments that are more culturally syntonic are likely to be more culturally acceptable, improve outcomes, increase adherence, and decrease treatment failure. It is quite possible that some treatments are more evidence-based for some populations than others. Autting this to a test would be a worthy endeavor.

As Hall et al. (2011) point out, there are certainly many similarities between Asian culture and mindfulness and acceptance-based psychotherapies. This is clearly evident given that many Asian religions and philosophical systems that focus on mindfulness (e.g., Buddhism, Taoism, and Confucianism) are deeply embedded in Asian culture. Mindfulness is based on Eastern concepts of self and other awareness, centering, balance, and meditation. Buddhist and Taoist masters have practiced meditation for thousands of years, and there are different levels of practice and goals for religious clergy and laypeople. Some mental health treatments that emphasize the particular values and traditions embedded in the culture of origin have already been developed (e.g., Japanese Morita and Naikan therapies: Morita, 1998; Reynolds, 1980). In fact, the creation of alternative forms of mental health treatments for different cultures around the world should also be discussed as a viable option. This makes sense given that many countries and cultures are heavily populated and are culturally different from the West. This may make less sense domestically given the diversity of groups living within the country, large proportion of immigrants in cultural transition, and the difficulty of training clinicians to conduct distinctly different therapies. Domestically, adapting therapies that are more culturally congruent may make more sense.

As the authors point out, much of Buddhism is focused on acceptance of life’s suffering and detachment from the world as a path to enlightenment. This is an important point that should not be taken lightly. In addition, it is also important to understand the cultural complexities involved, and to take care not to overly stereotype or rigidly interpret cultural characteristics and beliefs. The issue of “dynamic sizing,” (i.e., knowing when to stereotype and when not to overgeneralize) is complex and difficult because there is rarely a clear-cut and obvious answer (Sue, 1998). As a consequence, if a therapist does not possess effective understanding of an individual within a cultural context, they might focus too much on acceptance of the client’s life difficulties, and do less to help the patient change their life circumstances (e.g., problem solving, relationship building, and communication skills development).

Also, even though a client may be Asian American, the client may not effectively relate to cultural or cultural-religious teachings (e.g, there may be a wide diversity in levels of acculturation, religious affiliation, and individual differences). In addition, some clients have clinical issues that lead them to overly interpret cultural teachings in an unhealthy way. For example, there is a distinct difference between acceptance and fatalism—also a core part of Asian cultural values. A client could very easily use cultural or religious teachings as an excuse for not taking initiative, which further reinforces their problems (e.g., there is no point in trying, that's just the way it is, there's nothing I can do about it—“life is suffering”). Although Buddha did say that “life is suffering,” this overly rigid misinterpretation can be used by an individual as an excuse for inaction, and is likely a maladaptive clinical response that occurs within a cultural context. Buddha never argued for people to suffer meaninglessly, nor did he argue that we should not do our best to solve our problems. Therapists need to understand the complexities involved so that they do not trade seemingly culturally syntonic techniques, four strategies and techniques that can sometimes be clinically dystonic.

It is also important to remember that every culture is multi-faceted and contains a multitude of different values and beliefs. One could argue that problem-solving or solution-focused therapies could also be congruent with Asian values cultural and belief systems. Confucius taught the importance of virtue, morality, self-cultivation, and education as a way to solve problems and better. As a consequence, many Asians focus on problem-solving, and most clients that I have personally treated or have supervised therapists in treating have come to therapy with the goal of solving their problems or changing other people. It could be a mistake for a therapist to overly align with acceptance of life's problems and not align with the cultural emphasis of problem-solving. For example, if a therapist decides that they should try to get an Asian American client to accept the problematic situation and focus on mindfulness, the client may become frustrated with and never come back. A culturally competent therapist should be cognizant of the complexities involved, try to align with multiple cultural values, and maximize the ordering in which clinical techniques are implemented. One strategy would be to start with a problem focused strategy, and then focus on acceptance and helping the client find inner peace when nothing else can be done.

Recently, I developed a treatment manual titled “Improving Your Mood: A Culturally Responsive and Holistic Approach to Cognitive-Behavioral Therapy (CBT) for Chinese Americans” (Hwang, 2008). This treatment manual was developed through the collaboration of several ethnic-specific service clinics throughout California and a National Institute of Mental Health (NIMH) R34 grant. The second phase of the project tests cognitive behavioral therapy (CBT) with culturally adapted CBT, and is currently being finalized. Cultural metaphors and sayings which were integrated into the treatment can actually be quite healing for all cultures.

The cultural metaphor “山不轉路轉 ; 路不轉人轉 ; 人不轉心轉” used in the title of the manual illustrates the importance of ordering and the emphasis on multiple cultural values. This saying literally means if the mountain doesn't turn the road turns, if the road doesn't turn the person turns, if the person doesn’t turn then the heart and mind turns. Figuratively, it means that no matter how hard things get, there is always a solution. If you can't find a way past the mountains (obstacle), then find a road around it. If there is no road around it, then make your own path. If you have done your best and still can't change the situation or find a solution, then you need to change the way you think and feel about it. This type of saying can be incredibly healing, and could potentially be utilized in problem and solution-focused therapies (e.g., let's figure out how to solve the problem), mindfulness and acceptance-based therapies (e.g., it looks like we can’t change the other person or the situation, let's figure out how to make the most of it and put our mind at peace), as well as cognitive-behavioral therapy (e.g., now that we tried to resolve the problem, what's the most helpful and effective way to think about it).

By studying how therapy can be effective for people across cultures, we essentially improve the universal science of psychology and the effectiveness of mental health treatments for all people. Many cultural and philosophical sayings and concepts can generalize to people of different backgrounds. Hall et al. (2011) discusses how mindfulness can be especially effective for Asians, and there is also evidence that mindfulness can be effective for Westerners. Identification of universally effective treatment techniques can strengthen the core of therapeutic healing. Mindfulness is inherent in Buddhist and Taoist meditation. Mindfulness is also culturally syntonic with the Taoist concept of “yin yang” (balance and harmony), as well as the Buddhist principle of “yinguo” or cause-and-effect. Mindfulness is also integrated into therapeutic exercises such as yoga and tai chi, which have become a popular form of healing and exercise for people across the world.

In order to provide effective treatments for people of diverse backgrounds, we need to individualize treatments for clients. Graduate programs need to train therapists to understand the complex interplay between cultural and clinical issues. This requires therapist to learn about clients from diverse backgrounds, learning additional languages that help facilitate linguistic-Cultural Adaptations 11 cultural understanding, and understanding which therapies and therapeutic techniques can be aligned with the client’s cultural background.