Does Cultural Adaptation Have a Role in Substance Abuse Treatment?

Abstract

The changing ethnic composition of the nation and increasing requirements to use evidence-based treatments (EBTs) challenge mental health professionals to adapt treatments and interventions to be appropriate for their clients. This article applies the available information on cultural adaptation to substance abuse. The authors’ review suggests that the most common approaches for adapting substance use interventions include some combination of either community involvement in the adaptation, existing research and literature, and/or consultation from experts to adapt EBTs. The challenges facing the development of culturally adapted interventions include the need for additional research to determine which specific EBTs warrant adaptation, the responsibility of maintaining the balance between fidelity and adaptation, and the challenge of intragroup diversity.

In the constantly changing world of social services, two social trends will certainly affect the future delivery of substance abuse treatment services. First, rapidly changing demographics will challenge mental health professionals to provide culturally relevant services that match the needs, values, and beliefs of a more culturally diverse society. Second, local, state, and national funders will continue to demand evidence of the effectiveness of the programs they support (Bernal, Jimenez-Chafey, & Domenech Rodriguez, 2009; Castro, Barrera, & Holleran-Steiker, 2010; Miller, Zweben, & Johnson, 2005). These trends can create a certain amount of tension for mental health professionals trapped between external pressures to use evidence-based treatments (EBTs) and the reality that an “approved” intervention may be inappropriate for their specific target group.

This tension has not escaped substance abuse providers who, like their colleagues in other health services areas, may respond by culturally adapting EBTs to meet their target populations. Unfortunately, despite the emergence of several culturally adaptive frameworks and models, little concrete guidance is available to substance abuse providers serving more culturally diverse individuals and groups. The two objectives of this article address this gap. The first objective is to apply the available information on cultural adaptation methods to substance abuse specifically. The second objective is to organize the various approaches for adapting substance abuse EBTs into a few common methods. In addition, the article includes a discussion of challenges facing the development of culturally adapted interventions in the future and the implications for social work and other mental health practitioners.

Miller et al. (2005) published a seminal paper discussing the why, what, where, when, and how of substance abuse EBTs. This article, modeled from Miller et al.’s work, begins with the why, what, where and when of cultural adaptation. However, to accomplish the second objective of synthesizing the approaches, this article emphasizes the how by describing concrete strategies useful for adapting EBTs for specific target groups.

WHY CULTURALLY ADAPT?

Miller et al. (2005) raised the following thought-provoking question at the beginning of their article:

Suppose that you have a life-threatening illness and went for health care to a physician who told you, I really don’t pay much attention to medical research. I’ve been treating people like you for 30 years, and I know what works. Medical research isn’t all that relevant to my practice, and, besides, I’m too busy to read journals. Would you go back or would you find yourself another doctor? (p. 267)

Now, let’s take the Miller et al. analogy a bit further. Imagine that you also learned your physician uses the same dose of the same medication for all clients with the same medical disorder (regardless of gender, age, weight, differential diagnosis, preexisting conditions) without even considering whether available scientific evidence suggests certain types of patients are more or less likely to respond to that medication. Now, what’s the chance you would return for a second visit?

This medical analogy is similar to the dilemma facing substance abuse counselors and other health care providers when deciding on the appropriateness of a substance use behavioral intervention with unknown efficacy for one target group but demonstrated efficacy for another group. Various schools of thought have different positions on this issue. The universalist perspective argues that cultural adaptations are often unfeasible (Kazdin, 2000) and even unnecessary (Elliott & Mihalic, 2004). Moreover, the universalist camp cautions that adaptation, a potential threat to intervention fidelity, can decrease program effectiveness. For example, DePue et al. (2010), despite developing an effective cultural adaptation methodology, still questioned the extent to which an intervention can be adapted before becoming a different intervention altogether (i.e., throwing out the baby with the bathwater).

Conversely, cultural psychologists argue that cultural traditions and social practices influence behavior substantially. For substance abuse specifically, prior evidence demonstrates meaningful racial ethnic differences in drug histories (Shillington & Clapp, 2003), specific drugs used (Moselhy & Telfer, 2002), health consequences of substance use (Iguchi, 2005), and the relation of spirituality (Strada & Donohue, 2006) and acculturation (Epstein, Botvin, & Diaz, 2000; Hahm, Lahiff, & Gutterman, 2003; Klonoff & Landrine, 2000; Strada & Donohue, 2006) to substance use attitudes. In addition, important racial ethnic differences that may affect treatment response have been demonstrated such as pathways to treatment (Iguchi, 2005; Shillington & Clapp, 2003), patterns of treatment engagement and retention (Campbell, Weisner, & Sterling, 2006; Jackson-Gilfort, Liddle, Tejeda, & Dakor, 2001), and cultural attitudes about mental health treatment (Buser, 2009). Together, these differences raise serious concerns regarding a priori assumptions that interventions developed for one ethnic minority group are appropriate for another group.

The scholarly discourse on the advantages and disadvantages of cultural adaptation has primarily occurred outside the substance abuse field. Two recent meta-analyses (Griner & Smith, 2006; Smith, Domenech Rodriguez, & Bernal, 2011) and a review by Huey and Polo (2008) conclude that cultural adaptation improves outcomes. The recent meta-analysis by Smith et al. (2011) revealed not only that culturally adapted interventions were frequently more effective than generic interventions but also that the most effective interventions had more adaptations. In addition to studies specifically on cultural adaptation, other meta-analyses have demonstrated that “adapting or tailoring the therapy relationship to specific patient characteristics enhances the effectiveness of treatment” (Norcross & Wampold, 2011, p. 98).

Even though the discussion about cultural adaptations within the field of substance abuse has been fairly limited, several factors affirm such discussions. First, several recent analyses of large substance abuse data sets argue against a “one-size-fits-all” approach to EBT. The National Drug Abuse Treatment Clinical Trials Network (CTN) of the National Institute of Drug Abuse (NIDA), a collaboration of researchers and providers charged with evaluating substance abuse treatments in large, multisite clinical trials, has conducted some of this work. One recent CTN study demonstrated that Real Men Are Safe (REMAS), an HIV risk-reduction intervention for substance abusing men, was less effective with Black than White male substance users (Calsyn et al., 2011). Conversely, several other CTN studies revealed that interventions with limited effectiveness for White substance users were more beneficial for one or more racial ethnic minorities (Covey et al., 2010; Montgomery, Burlew, Kosinski, & Forcehimes, 2011; Winhusen et al., 2008).

Second, compelling evidence suggests that culturally adapting substance abuse prevention and treatment interventions can improve the outcomes for target groups. More than two decades ago, Botvin et al. (1995) showed that a culturally adapted version of Life Skills Training (LST), a prevention intervention aimed at delaying the onset of smoking, yielded better prevention outcomes with urban Black youth than the generic version. More recently, other researchers demonstrated the benefits of a culturally adapted version of the Strong Families Program (Brody et al., 2006) and the Strengthening Families Program (SFP) (Spoth et al., 2003) for preventing substance use among Black youth. Two other treatment studies suggest that culturally adapted versions may improve treatment outcomes for Black substance abusers as well. First, Longshore and Grills (2000) culturally adapted Motivational Enhancement Therapy (MET) by creating a culturally familiar experience at the beginning of treatment (e.g., adding a same-race peer to the counseling team who was in recovery, showing a video depicting drug use as a personal and community issue, building rapport by beginning therapy with a meal with the peer and professional counselor). The participants in a culturally adapted version of MET were more likely than the participants in the generic MET to be abstinent 2 years after treatment (Longshore & Grills, 2000). Second, Calsyn et al. (2013) culturally adapted REMAS by addressing the sociocultural factors associated with HIV risk behaviors among ethnic minority males abusing substances. Their results demonstrated that ethnic minority men abusing substances who participated in a culturally adapted version of REMAS were more likely to reduce their HIV risk behaviors than men in the generic version of REMAS (Calsyn et al., 2013).

WHAT IS CULTURAL ADAPTATION?

Cultural adaptation has been defined as the “systematic modification of an EBT or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meaning, and values” (Bernal et al., 2009, p. 362). Castro et al. (2010) conceptualize cultural adaptation as a compromise on a continuum ranging from a universalist perspective, which favors the implementation of the generic intervention without modification at one end, to a culturally tailored intervention, developed for a specific group, that typically does not start with a generic intervention at the other end.

A culturally adapted intervention maintains the core components of an EBT but translates the EBT to be more relevant and consistent with the ideas, values, beliefs, norms, attitudes, and knowledge of the target group (Copeland, 2006; Falicov, 2009). The adapted version addresses the cultural, social, and contextual factors related to the problems the target group brings to treatment. The remainder of this section reviews several issues related to cultural adaptation including the emphasis on adding cultural, social, and contextual factors to the intervention and incorporating empowerment into the adapted version.

Incorporating a Focus on Cultural, Social, and Contextual Factors

The proposition that providers should consider cultural, social, and contextual factors is certainly not new to social sciences. Four decades ago, Gordon Paul (1967) recommended that clinicians consider “What treatment, by whom, is most effective for this individual, with that specific problem, and under which set of circumstances?” (p. 11). The classic ecological systems theory (EST) (Bronfenbrenner, 1979) emphasized the role of social and cultural factors in initiating and even maintaining new behaviors. During the 1990s, Tharp (1991) proposed in his cultural compatibility hypothesis that treatments compatible with the client’s cultural norms are more likely to be effective. More recently, Cauce et al. (2002) asserted that the sociocultural context is essential throughout the help-seeking process from the acknowledgment of needing help, to seeking help, and choosing a helper. However, Cauce et al. argued that even theorists who include other contextual factors (socioeconomic status [SES], gender, region) in their models frequently fail to consider culture adequately. Two recent theoretical models, the sexual health model (Wyatt, 2009) and the person, environment, neighborhood (PEN-3) model (Airhihenbuwa et al., 2009) build on EST by adding an emphasis on socio-contextual factors. Moreover, both approaches stipulate that interventions that ignore the sociocultural setting in which behaviors occur are less likely to be effective.

The culturally adapted REMAS intervention mentioned above is an example of an intervention in which the adapted version included more focus on sociocultural and contextual factors (Calsyn et al., 2012). The generic REMAS, which focused less on sociocultural factors, was relatively less effective for reducing HIV risk among Black than White men. However, the culturally adapted version that placed more emphasis on the influence of social cultural factors on sexual decision making (e.g., the impact of the social setting on the socialization experiences of participants about appropriate sexual behaviors and social interactions about sex) was more effective with ethnic minorities (Calsyn et al., 2013).

Promoting Empowerment in Cultural Adaptation

In 1990, Gutierrez provided a conceptual framework for including an empowerment component when working with women of color. She described empowerment as the “process of increasing personal, interpersonal, or political power so that individuals can take action to improve their life situation” (p. 149). This focus is very consistent with Standard 6 of the NASW Standards for Cultural Competence in Social Work Practice of the National Association of Social Workers (NASW). Standard 6 argues for “The promotion of the combined goals of consciousness raising and developing a sense of personal power and skills while working toward social change” (NASW, 2001, p. 24).

In addition to the appeal of an empowerment approach as a strategy for affecting social change, the available evidence suggests clinical reasons to promote empowerment as well (Austin & Harris, 2011; Gutierrez, 1990). Therapeutic interventions that instill a realistic sense of personal control and personal responsibility can facilitate skill development for the client to change not only the problem behaviors (e.g., substance abuse) that led to treatment but also to withstand broader contextual factors (e.g., discrimination) possibly related to the maintenance of behavioral change (e.g., avoiding relapse). Conversely, individuals who feel powerless are frequently less aware of their choices and opportunities (Austin & Harris, 2011; Gutierrez, 1990). Specifically, Austin and Harris (2011) argue that clients who perceive themselves as powerless to challenge interpersonal, social, and societal inequities are more likely to present with poor coping skills that ultimately adversely affect their response to treatment.

Although the available information on therapeutic approaches promoting empowerment is limited, Gutierrez (1990) identified four psychological changes that accompany a sense of empowerment. These include (a) increasing self-efficacy, (b) developing group consciousness, (c) reducing self-blame, and (d) encouraging participants to assume personal responsibility for change. Moreover, Gutierrez suggests that the following skills promote empowerment: (a) accepting the client’s definition of the problem, (b) identifying and building upon existing strengths, (c) engaging in a power analysis of the person’s situation (i.e., greater awareness of one’s power helps the client to experience himself or herself as a powerful, capable person), (d) teaching specific skills (e.g., problem-solving), and (e) mobilizing resources and advocating for the client. Clearly, translating these strategies into specific activities will enhance the outcomes of an adapted version of an intervention with vulnerable populations as the target group (pp. 150–151).

Where?

The appropriateness of specific culturally adapted interventions will vary across treatment sites according to methods of intervention (e.g., length and number of sessions, individual vs. group treatment, staff qualifications, and other constraints on service provision). In addition, the racial ethnic composition of the clientele may also affect the feasibility of using a culturally adapted intervention. An ethnically diverse clientele presents even more of a challenge when culturally adapting group rather than individual interventions. Yet, due to the current economic climate, most agencies find it challenging to offer group-based interventions for each specific ethnic group served by the agency. When the setting requires the clinician to adapt the intervention for use with more than one racial ethnic group, it may be feasible to adapt the intervention by emphasizing issues related to substance abuse or treatment that are common to the various groups. For example, acculturation issues may be relevant to treatment response across immigrant groups. Similarly, a multicultural group of men may all benefit from gaining insight into how the sociocultural experience of being a man of color without the inherited privileges afforded to non-Hispanic White males is related to their substance use. A diverse group of women may benefit from discussions of the impact of issues such as trauma or abuse, custody issues, low socioeconomic status, the experience of being a mother, wife or partner, and so on on the problems they bring to treatment (Greenfield et al., 2007).

Including activities to increase participants’ understanding of the role of cultural and contextual factors to substance use may be feasible even when the specific experiences of participants vary. For example, even though one group member might disclose that gang membership initiated his or her drug use whereas another might describe how the constant uprooting from being raised in a military family provided the impetus for drug use, both might be able to relate to the more general theme that the same external, social forces that led to past drug use may affect their future sobriety. The lack of attachment and diffused boundaries within the familial relationships could be a common factor among many substance users.

The culturally adapted version of REMAS is an example of an adapted intervention that emphasized the influence of cultural and social factors on sexual risk behaviors for implementation in a diverse group in which the specific cultural and social backgrounds of the participants varied widely. The diverse groups primarily included Hispanic, Black, and non-Hispanic White participants. During focus groups conducted after the trial with a subgroup of participants, Calsyn et al. (2013) asked participants for feedback regarding whether the mixed groups detracted from the group experience. Even though Calsyn et al. (2013) would have been pleased if the men did not report any negative aspects of participating in an ethnically diverse group, the team was pleasantly surprised when the men reported that the diversity of the group had actually been an asset. Specifically, the men reported that listening to other men becoming more aware of the influence of background factors on their sexual decision making increased their insight into the effect of their own background even though their specific backgrounds were substantially different. This finding is consistent with earlier work by Yalom (1970) who reported that heterogeneity improves group functioning because clients benefit from hearing varied points of view.

When?

Obviously, culturally adapting every intervention for every target group is unrealistic and even counterproductive. Instead, Lau (2006) recommends that the decision to adapt should be “selective and directive.” Therefore, one of the first tasks is to determine whether sufficient research has been conducted to determine whether a generic intervention is effective for a specific target group. Accordingly, an initial question might be whether the existing research is applicable to a specific group. Huey and Polo (2008) proposed that, for the evidence of effectiveness to be applicable to a specific ethnic minority target group, the research on a specific intervention must meet at least one of the following criteria: (a) the target group should have constituted at least 75% of the sample, or (b) separate analyses should have been conducted specifically on the target group, or (c) analyses were conducted to demonstrate that race or ethnicity did not moderate the relationship between treatment type and outcomes.

Along with determining whether the existing research is applicable to a specific group, Lau (2006) suggests any of the following circumstances might indicate that modifying generic interventions is appropriate: (a) evidence of ineffective clinical engagement within the target group, (b) unique risk or resilience factors in a target group, (c) unique symptoms of a disorder in a target group, and (d) evidence of limited effectiveness with a particular target group.

Finally, adaptation is warranted when evidence suggests the generic intervention is harmful. The general assumption is that behavioral interventions may be ineffective but not harmful. Yet some evidence demonstrates that an intervention helpful with one group may even be potentially harmful for another group (Dishion, McCord, & Paulin, 1999). Specifically, they reported that the same group intervention that improves behavior among certain youth had the iatrogenic effect of reinforcing deviant behavior in more deviant youth. Obviously, the potential for harm represents another reason to evaluate the efficacy of an intervention for the target group.

How?

Determining “how” to adapt an intervention is, understandably, more formidable than the why, what, when, or where questions raised above. Fortunately, several useful frameworks and a number of cultural adaptation methods are available. These are described below.

Frameworks

Two broad frameworks established the foundation for the early thinking about cultural adaptations and remain in the forefront today: the ecological validity framework (EVF) and the cultural sensitivity framework (CSF). The EVF, one of the earliest frameworks, identifies the following eight potential areas to include in the adaptation: (a) language, (b) persons, (c) metaphors, (d) content, (e) concepts, (f) goals, (g) methods, and (h) context (Bernal, Bonilla, & Bellido, 1985; Bernal & Sáez-Santiago, 2006). Rossello, Bernal, and Rivera (2008) used this framework to adapt an intervention for Puerto Rican adolescents experiencing depression. Their focus was on two areas: content and methods. To address content, they revised some activities of the intervention to emphasize familisimo and respeto—two cultural values among Puerto Ricans. They modified the intervention by adding parental involvement to the intervention. The team then conducted a randomized clinical trial that demonstrated the efficacy of the culturally adapted version.

Several years later, Resnicow, Soler, Braithwaite, Ahluwalia, & Butler (2000) proposed the CSF that organizes cultural adaptations into two broad categories: surface and deep structural interventions. Even though surface adaptations alter the presentation of intervention activities (e.g., case scenarios using characters from the target group, using treatment staff from the target group) to produce interventions more acceptable or familiar to the target group, surface adaptations do not change the core curriculum of the intervention. For example, Botvin et al. (1989) used a surface approach to modify Life Skills Training, an intervention aimed at reducing the onset of smoking among middle-school children. The team altered the intervention by changing the ethnicity of mythical figures in the curriculum, replacing the original heroes in the stories with heroes familiar to the ethnic group, and adding culturally appropriate videos. However, they left the original message unchanged.

Deep structural adaptations in the CSF framework revise core treatment components to align better with the culture, social experiences, and values of a particular racial ethnic group (Resnicow et al., 2000). One advantage of deep structural approaches is the possibility of incorporating cultural strengths in the adapted version. For example, Gone (2008) reported that that culturally adapted interventions within Native American mental health services that build on cultural rituals have better outcomes than adapted versions of interventions that retain what Gone calls “neo-colonial and assimilative” encounters with the treatment team. Similarly, Brody et al. (2006) first studied the cultural norms of the group to incorporate cultural strengths in the modified version. Once their research revealed that “regulated communicative parenting” (e.g., limit setting, monitoring, racial socialization, clear expectations about alcohol use, communication, and consistent discipline) was a protective factor for rural adolescents, Brody et al. used that information to modify the parental component of the Strong Families Program to create the Strong African American Families program.

More recently, Hwang (2006) developed a third framework for cultural adaptation: the psychotherapy adaptation and modification framework. That framework identifies the following six domains as a guide to adaptation: dynamic issues and cultural complexities (e.g., understanding the multiple identities of a client), orientation to therapy, cultural beliefs, client-therapist relationship, cultural differences in expression and communication, and salient cultural issues).

Cultural adaptation methods

The early frameworks laid the foundation for the development of a number of alternative methods or general procedures for cultural adaptation. Even though multiple models are available, several common approaches to cultural adaptation appear to characterize the models. Table 1 summarizes a number of methods for cultural adaptation. The three most common approaches include (a) community involvement (involving members of the community and/or target group in modifying the intervention), (b) reviewing existing literature and research on the target group to identify the areas to address in the culturally adapted version, and (c) consultation from experts in either cultural adaptation or on the problem bringing the client to treatment.

TABLE 1.

Cultural Adaptation Model

Method	Description	Approaches
Cultural accommodation model   (Leong & Lee, 2006)	Based on the tripartite model of personality (Kluckhorn & Murray, 1948).	Review of existing literature and   research
	Three steps for cultural adaptation: Identify cultural gaps Review the literature to select culturally specific concepts to address the missing components Test to determine whether adapted theory or model has incremental validity above unaccommodated theory or model
Cultural adaptation process   model (Domenech Rodriguez & Wieling, 2004)	Expands the ecological validity model by adding three phases and ten specific target areas.   Phase 1 outlines the iterative process among all parties involved in the adaptation   process. Phase 2 involves the selection and adaptation of evaluation measures, and Phase   3 focuses on integrating the observations and data gathered to create a new intervention.	Review of existing literature and   research
		Experts
		Community involvement
		Needs assessment
	Phase 1: Change agent (CA) & opinion leader (OL) collaborate OL meets key community leaders to examine interest and conducts needs assessment OL assesses community need; evaluates adaptations to intervention OL examines innovation fit with minority mental health literature
	Phase 2: OL and CA tailor the intervention a priori OL tests and revises the intervention by observing the adaptation and incorporating reintervention, with consultation from CA OL evaluates measures for theoretical and cultural appropriateness OL tests and revises the intervention with input from CA
	Phase 3: Adaptations to new intervention and measurements are created Replicate entire process (might incorporate new OLs)
Hybrid prevention program   model (Castro, Barrera, & Martinez, 2004)	Objective is to create a “culturally equivalent” version by matching the intervention to   group characteristics, program delivery staff, and administration and/or community   factors	Review of existing literature and   research
	Three dimensions to address: Adapting the intervention to be consistent with Cognitive-information processing characteristics to match language and age/development Affective-motivational characteristics (e.g., socioeconomic status, ethnicity) Environmental characteristics of the local community	Community involvement
Heuristic framework (Barrera & Castro, 2006)	Based on Lau’s (2006) analysis of EBTs. Framework proposes a tripartite framework with   subcomponents that evaluate the equivalence of engagement, the ability of treatment to   change mediating variables, and the relationships between mediators and treatment   outcomes. Incorporates clinical judgment and cultural competence into cultural adaption   framework.	Review of existing literature and   research
		Community involvement
	Four step process: Search the literature for promising ideas, conduct quantitative surveys, and conduct qualitative research. Make preliminary adaptations Test the preliminary adaptations in case or pilot studies Refine adaptations
Culturally specific prevention   (Whitbeck, 2006)	Method includes heavy involvement of local community stakeholders with research team.	Review of existing literature and   research
	Five stages: Identify key risk and resilience factors identified by majority researchers Examine research on risk and protective factors for the specific ethnic minority group Work with cultural experts to translate the relevant risk and resilience factors to fit the cultural context. Develop measures of risk and resilience factors that are appropriate for the cultural context Conduct trials of culturally specific intervention trials	Community involvement
		Experts
Integrated bottom-up approach to   adapting psychotherapy   (Hwang, 2009)	Integration of the “bottom up” Formative Method for Adapting Psychotherapy (FMAP)   (Hwang, 2009).	Review of existing literature and   research
	Bottom Up: Five phases Generate knowledge and collaborate with stakeholders Integrate information with theory and empirical and clinical knowledge Review the initial culturally adapted clinical intervention with stakeholders and revise the culturally adapted intervention Test the culturally adapted intervention Finalize the culturally adapted intervention	Community involvement
		Experts
Adaptation for international   transport (Kumpfer, Pinyuchon, de Melo, & Whiteside, 2008)	In order to maintain fidelity, cultural adaptation does not include modification of program   components, timings, or overall structure (Kumpfer et al., 2008). However, the following   strategies are used to make appropriate modifications:	Community involvement
		Review of existing literature and   research
	Gather needs assessment data on etiological precursors Carefully select the best EBT to culturally adapt Implement original intervention with only minor modification Carefully select staff and provide training/supervision to assure quality implement Implement program with fidelity and quality Make interventions continuously based on feedback from pilot group Revise program to improve engagement Evaluate empowerment to improve outcomes with attention to cultural appropriateness of instruments and procedures used Disseminate results of the effectiveness of the culturally adapted intervention	Needs assessment
Culturally adapted CBT for   African and Caribbean   Americans (Rathod, Kingdon, Phiri, & Gobbi, 2010)	Focus groups and interviews were conducted with potential patients, therapists, and mental   health practitioners on strategies for tailoring CBT to ethnic minority patients. In patients   with psychosis, researchers describe modifications in the following four areas: Preengagement and engagement Assessment and case formulation Delusions and hallucination Treatment barriers	Community involvement
Cultural adaptation of   psychoeducational preventive   intervention (Podorefsky, McDonald-Dowell, & Beardslee, 2001)	Provides contextual factors which researchers and clinicians should adhere to when   adapting programs to any settings: Reconceptualize disorder to reflect contextual phenomena Use an ecological approach to community building Emphasize on behaviors that promote resilience and adaptability which are relevant to the context of the target group. Ensure greater availability and flexibility in program staff. Apply core principles that guide approach and allow significant modifications in the delivery of the intervention.	Needs assessment
		Experts
ADAPT-ITT (Wingood & DiClemente, 2008)	The modification proceeds through the following stages used for adapting HIV prevention   programs: Assessment (e.g., focus groups, interviews, and needs assessments with target population) Deciding on the appropriate intervention by reviewing the literature on appropriate HIV intervention Using an innovative theater testing model to collect feedback on the generic intervention from representatives of the target population, key stakeholders, and mental health professionals Production of a draft adapted version Topical experts (consultation with experts) Integrate content suggested by topical experts into the adapted version. Training personnel Testing (pilot test) and collect exit interviews from participants; collecting a randomized clinical trial	Experts
		Community involvement
Implementation of cultural   treatments to groups in San   Francisco (Muñoz & Mendelson, 2005)	This modification includes the following elements: Involve members of the ethnic minority target group in the development of the intervention Acknowledge and integrate relevant cultural values into the intervention Consider whether incorporating religion and spirituality into the intervention would improve outcomes Address an relevant acculturation issues or dilemmas clients may face in negotiating cultural differences Build in opportunities to acknowledge the existence and impact of racism, prejudice, and discrimination in the lives of clients	Community involvement
(Domenech Rodriguez, Baumann, & Schwartz, 2011)	This method included the following guidelines: Involve the target population Involve treatment providers who are knowledgeable about the target population Plan the adaptation of the treatment or intervention Conduct a preliminary pilot study on the acceptability and feasibility of the treatment intervention Review the literature on issues, themes, and constructs with the barriers to treatment with the particular population Consider specific details of delivery	Experts
Cultural intervention for diabetes   patients (DePue et al., 2010)	Incorporated the following steps: Gather background information and research on background and culture Convene preliminary community meetings Select evidence-based studies to translate Conduct formative studies (e.g., focus groups) Culturally translate measures Adapt intervention Implement randomized controlled trial Conduct posttreatment qualitative studies Interpret study results with community partners	Review of existing literature and   research
		Community involvement
Centers for Disease Control map   of adaptation process   (McKleroy et al., 2006)	Five key steps to cultural adaptation: Assessment: target population’s risk factors, behavioral determinants, risk behaviors; potential evidence-based treatments and their internal logic; stakeholders, potential collaborators; agency’s capacity to implement the intervention Selection: use assessment data to select treatment and determine if adaptation is needed Preparation: make necessary changes to EBI (but maintain fidelity to core elements); prepare the organization; pretest with focus groups, test materials for reading level, attractiveness Pilot test the adapted intervention Implementation: with conscientious monitoring of fidelity and outcomes	Community involvement; experts;   needs assessment

EBT = evidence-based treatment; CBT = cognitive-behavioral therapy; ADAPT-ITT = Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, and Testing; EBI = evidence-based intervention.

Community involvement in both the modification of the intervention and the review of existing literature and research are two common approaches. Community involvement can be very helpful in determining what Castro refers to as the “social validity” or the perceived acceptability and utility of the intervention among the target group (Barrera & Castro, 2006). The community participants vary across methods from mental health professionals (Wingood & DiClemente, 2008), community leaders (Domenech Rodriguez & Wieling, 2004) to members of the target group (Wingood & DiClemente, 2008). Some academicians simply confer with the community; however, others form collaborations with the community to adapt the intervention (e.g., DePue et al., 2010; Muñoz & Mendelson, 2005; Podorefsky et al., 2001). Even though the target group can provide a unique perspective about the potential effectiveness of intervention activities, a meta-analysis by Griner and Smith (2006) revealed that members of the target group were rarely included in previous cultural adaptations of interventions. Wingood and DiClemente’s Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, and Testing (ADAPT-ITT) model (2008) offers a very creative approach to involving the target group in adapting a group EBT. Specifically, in the theater testing phase of ADAPT-ITT, target group members serve as mock “participants” in an enactment of the generic intervention in the presence of key stakeholder and agency staff. Afterwards, the facilitators engage the participants and observers in a discussion regarding both the relevance of the intervention content for the target group and strategies for increasing intervention effectiveness with the target group.

The second approach typically includes a careful review of available research and literature on the etiology of the problem behaviors and the available information on the engagement, retention, and/or response to treatment of that target group. The Culturally Specific Prevention (CSP) approach that Whitbeck (2006) developed originally to culturally adapt prevention interventions for Native Americans is an example of this approach. The CSP method begins with a review of research on relevant risk and protective factors that characterize a specific cultural group. That research is then used to adapt the selected EBT.

Consulting with experts, the third approach, has the obvious advantage of benefiting from the skills and knowledge of other professionals. The cultural adaptation process model uses cultural experts but their role appears restricted to identifying appropriate measures for the target group (Domenech Rodriguez & Wieling, 2004). The ADAPT-ITT model includes “topical experts” who may have experience in specific content areas (e.g., family therapy, prevention) with the target group. However, even though both of these methods use experts familiar with the cultural group, neither involves experts with prior experience specifically in the cultural adaptation of intervention with other groups. Calsyn’s team (2012) engaged scholars and clinicians with prior experience specifically in cultural adaptation. The case study below describes their process.

The Use of Experts to Adapt REMAS

As stated previously, the impetus to culturally adapt/enhance REMAS was driven by findings that indicated REMAS was less effective with Black compared to White men who abused substances. The procedures utilized to culturally adapt REMAS were driven by (a) the literature on approaches to culture adaptation, especially Resnicow et al. (2000), Wingood and DiClemente (2008), Castro, Barrera, and Holleran-Steiker (2010), Bernal and Scharró-del-Rio (2001), Dévieux et al. (2005), Castro and Garfinkle (2003), Bernal, Bonilla, and Bellido (1995), and Yuen (2004); (b) the availability of evidence-based culturally tailored HIV prevention interventions already vetted by the CDC’s Research Synthesis Project; (c) the potential utility of using the Delphi process (De Villiers, De Villiers, & Kent, 2005) as the mechanism for a culturally informed revision; and (d) the need to have an intervention that could be utilized with an ethnically diverse group of men because offering multiple culturally tailored interventions targeting each racial ethnic subgroup would be impractical in most substance abuse treatment programs.

The REMAS cultural adaptation/enhancement process involved the following steps: (a) an expert panel was recruited that included three academic cultural adaptation experts and six substance abuse treatment providers experienced in treating African American and or Hispanic men (consistent with the Delphi process, all panel members were unknown to each other); (b) currently available evidence-based culturally tailored HIV prevention interventions were identified and, as much as possible, their modules were paired with REMAS modules of similar content; (c) rating forms were developed to measure cultural relatedness. Based on previous work by Bernal et al. (1995) and Yuen (2004), the modules were rated on the following five dimensions: (1) use of language, idioms, and expressions of the target group; (2) use of the symbols and concepts of the target population; (3) presentation of the material in a manner consistent with the knowledge, cultural values, and customs of the target group; (4) incorporation of activities that enhance ethnic identity; and (5) use of materials that demonstrate an understanding of the social context that surrounds the behavior and living situation of the target group. The rating forms instructed the panel members to rate each module on a 1 to 5 metric. For example, on the language/expression dimension, panel members rated the modules on a scale ranging from 1 (high use of unfamiliar language/expressions for target group) to 5 (high use of unique language/expressions for target group). Separate ratings were generated for use of the modules with Black and Hispanic men.

In round 1 of the Delphi process, the team supplied expert panel members with published articles on cultural adaptation to provide a conceptualization for the process, intervention modules from REMAS paired with modules from the culturally tailored interventions, and the rating forms described above. Panel members reviewed the materials and completed the rating forms independently. A rating difference between a REMAS module and any corresponding culturally tailored module for either African Americans or Hispanics of greater than 0.5 was a priori identified as rationale for a possible major revision of the REMAS module. Panel members were also asked to make specific recommendations for revision to REMAS. Utilizing ratings and recommendations obtained from the panel, a draft version of REMAS Culturally Adapted (REMAS-CA) was developed. In round 2 of the Delphi process, REMAS-CA was reviewed by panel members who provided ratings on readiness for pilot testing and made further suggestions for revisions. Although the panel suggested a few minor revisions for the pilot version, the overall consensus was that REMAS-CA was ready for pilot testing. A third round of the Delphi process including further review, ratings and feedback would have been conducted if the panel had not agreed that REMAS-CA was ready for pilot testing. REMAS-CA was pilot tested in four community substance abuse treatment programs with high prevalence of Black and/or Hispanic men. Focus groups were conducted with participants at the end of the pilot and exit interviews were conducted with counselors delivering the REMAS-CA intervention.

As noted previously, findings from the pilot indicated REMAS-CA was more effective for ethnic minority men than had been the case in the original REMAS study. Nevertheless, final revisions were made to REMAS-CA based on feedback from patient focus groups and counselor exit interviews.

Overview of Cultural Adaptation Methods

Several trends are evident in Table 1. First, including more than one method in the cultural adaptation is fairly common. Second, considerable variability is evident even within methods. For example, the heuristic framework would test the adapted version that results from community involvement and the review of existing research and literature by conducting case or pilot studies (Barrera & Castro, 2006). However, the method that Rathod, Kingdon, Phiri, and Gobbi (2010) used to develop a culturally adapted version of a CBT intervention included community involvement but no case or pilot studies. Finally, some of the approaches add a needs assessment (Podorefsky et al., 2001; Wingood et al., 2008). The needs assessment approach is useful not only for tailoring the intervention to a specific location but also for increasing community engagement for the project.

Culturally Appropriate Practice

Practitioners will inevitably encounter situations in which no adapted versions of the generic intervention have been developed for the clients they are serving. In those instances, practitioners may lack the time or resources to utilize one of the models described earlier to formally adapt an EBT. Nevertheless, in those instances, the practitioner may believe that the client(s) will be better served if the professional provides culturally appropriate practice. Unlike culturally adapted interventions, culturally appropriate practice offers a set of techniques to integrate cultural considerations into any therapy. Hays (2009) identified the following 10 steps to culturally competent practice:

1. Evaluate the individual and family needs, focusing on behaviors that are culturally respectful.

2. Identify resources (interpersonal and environmental) related to cultural strengths.

3. Clarify the nature of the problem (environmental, individual) and attend to cultural influences.

4. Focus on environmental challenges by supporting the client in minimizing stressors and maximizing personal strengths, support, and more positive relations with the social and physical context.

5. Acknowledge and support the client’s report of discrimination and other experiences of oppression.

6. Support collaboration vis-à-vis conflict attending to differences between the client and therapist.

7. Question the utility of “dysfunctional thoughts” or “irrational beliefs” in cognitive restructuring.

8. Avoid challenging cultural beliefs.

9. Develop a list of cultural strengths and supports to replace thoughts and beliefs considered unhelpful.

10. Provide regular homework, giving emphasis to the client’s goals and cultural congruence. (based on Hays, 2009, pp. 356–358)

CHALLENGES TO CULTURAL ADAPTATION

Several issues challenge the development of cultural adaptations. These include (a) the need for more research to determine which specific EBTs warrant adaptation, (b) maintaining the balance between fidelity and adaptation, (c) the use of culturally competent research methods, and (d) intragroup diversity. Each of these issues is discussed below.

More Research to Determine the Specific EBTs Warranting Adaptation

The efficacy of many available generic EBTs for specific ethnic minorities is untested. Those EBTs that have been tested generally fall into one of two categories. Some EBTs have demonstrated effectiveness for specific ethnic groups (Burlew, Burlew, Peteet, Johnson, & Smith, 2010; Huey & Polo, 2008; Miranda, Azucar, Organista, Dwyer, & Areane, 2003; Szapocznik, Prado, Burlew, Williams, & Santisteban, 2007). Others have been demonstrated to be ineffective for specific ethnic minority groups (Calsyn et al., 2012). However, in addition to those two outcomes, as described earlier, research suggests that a few interventions can even be potentially harmful for a specific ethnic group (Dishion et al., 1999). Since empirical evidence is unavailable for evaluating many EBTs, more research is needed to determine which interventions warrant cultural adaptation.

The underrepresentation of ethnic minorities in clinical trials (Mak, Law, Alvidrez, & Pérez-Stable, 2007, p. 12) is a barrier to differentiating between generic interventions that are effective with specific ethnic groups and those that require adaptation. The Minority Interest Group of the CTN recently published a review of effective strategies for increasing either recruitment or retention within CTN studies and in the broader literature (Burlew et al., 2011). Along with community involvement, our review showed that the cultural adaptation of the recruitment process increased the inclusion of ethnic minorities in clinical research. Several “deep structural” techniques were especially effective. Some examples include the redesign of interventions to be appropriate for implementation in familiar settings such as barber shops and beauty salons, spending more time addressing cultural mistrust by describing the care given to protect confidentiality, gaining community support by establishing collaborations with community and social service agencies, scheduling sessions outside of normal business hours, and meeting with participants in public places and other nontraditional settings at the participant’s request. However, because the studies were not designed to test the efficacy of the specific strategies on recruitment, engagement, or retention, the designs frequently included multiple strategies. That practice makes it particularly hard to determine which strategies are effective. Consequently, more research designed to examine specific components of inclusion is needed.

Maintaining the Balance between Fidelity and Adaptation

As the number of cultural adaptation methods continues to proliferate, maintaining the balance between fidelity and adaptation will continue to be a concern. Castro, Barrera, and Martínez (2004) refer to this as the fidelity-adaptation tension. In 2002, Substance Abuse and Mental Health Services Administration published an extensive report on establishing the balance between fidelity and adaptation in substance abuse prevention (Backer, 2002). Although these recommendations were not necessarily designed to promote cultural adaptation, they may be useful for maintaining core components of the intervention while adapting the intervention to a specific cultural group.

The main conclusion of the report based on a review of 117 published and unpublished studies is that “attention to BOTH fidelity and adaptation is essential for successful implementation of evidence-based substance abuse prevention programs” (Backer, 2002, p. 13). In addition, the report includes the following six recommendations for adaptation:

1. Identify and understand the theory base behind the program.

2. Locate or conduct a core components analysis of the program.

3. Assess fidelity/adaptation concerns for the particular implementation site.

4. Consult as needed with the program developer to review the above steps and how they have shaped a plan for implementing the program in a particular setting.

5. Consult with the organization and/or community in which the implementation will take place.

6. Develop an overall implementation plan based on these inputs. (Backer, 2002, pp. 16–17)

These recommendations, although not designed specifically to promote cultural adaptation, may be useful for maintaining the core components of the intervention while adapting the intervention to a specific cultural group.

The Use of Culturally Competent Research Methods

The National Institutes of Health (NIH) guidelines for the inclusion of women and minorities as subjects in clinical research mandate valid analysis along with the inclusion of the ethnic minorities in clinical research. A comprehensive discussion of culturally competent research methods is beyond the scope of this article. However, we refer interested readers to our earlier discussion on two important issues: data analysis and measurement (Burlew, Feaster, Brecht, & Hubbard, 2009). In that article, we cautioned against the reliance on race comparison designs, the use of measures developed for another group without examining their appropriateness for a different ethnic group, the shortcomings associated with combining ethnic groups for data analysis rather than using designs that consider group diversity, and the need for within group studies to identify subgroup differences. Using culturally competent research methods will yield better information about substance abuse among racial ethnic minorities. Barrera and Castro (2006) identified the following three research areas for determining the direction for cultural adaptation: (a) engagement, (b) the impact of an intervention on mediating variables (action theory), and (c) the extent to which an intervention changes the relation of mediators to outcomes (conceptual theory).

Intragroup Diversity

Intragroup diversity can be a challenge to adaptation within diverse subgroups of ethnic groups For example, Williams et al. (2007) reported that Caribbean born Black men were more at risk for psychiatric disorders than African American men. Accordingly, culturally adapted interventions for Caribbean men may require more attention to co-occurring disorders than similar interventions for African American men. Similarly, interventions developed for urban Black adolescents may require modification to be effective for rural Black adolescents. Moreover, interventions developed for college-educated suburban Blacks may require some modification to be appropriate for inner-city Blacks with less education. Intragroup diversity may be at least as much of a challenge for working with Hispanic, Native American/Alaska Native, and Asian groups as well. Therefore, examining the efficacy of an intervention for specific subgroups may sometimes be warranted. Barrera and Castro’s notion of adding decision rules for adapting interventions and adding guidelines to tailor interventions to specific subgroups may be useful for addressing intragroup diversity (Barrera & Castro, 2006). Similarly, Kumpfer, Pinyuchon, de Melo, and Whiteside (2008) propose to provide group leaders with a menu of options for implementing specific activities to increase the likelihood that the community will respond favorably to the intervention.

SOCIAL WORK IMPLICATIONS

Increasing the number of interventions with demonstrated efficacy for various racial, ethnic, and cultural groups is both an important step toward reducing health disparities and also consistent with the push for incorporating cultural competence in social work practice. These approaches create a more culturally relevant environment for service delivery. However, achieving these goals will require a great deal of support and resources from the social service community.

Culturally relevant interventions are consistent with NASW standards for developing cultural competence in social work practice (NASW, 2001). Standard 3 indicates that social workers have the responsibility to be knowledgeable about the clients they serve: “Social workers shall have and continue to develop specialized knowledge and understanding about the history, traditions, values, family systems, and artistic expressions of major client groups that they serve” (p. 4). However, Standard 4 encourages social workers to apply that knowledge to their work with clients: “Social workers shall use appropriate methodological approaches, skills, and techniques that reflect the workers’ understanding of the role of culture in the helping process” (p. 4). Together, these standards affirm that one-size-does-not-fit-all. Instead, more flexibility in treatment approaches is required. Culturally adapted interventions represent one strategy for social workers to implement their understanding of the consumer’s culture and its importance to the helping process.

The identification of effective interventions will require adequate allocation of funding for developing and testing culturally adapted interventions. A related issue is that many interventions developed by and for ethnic minorities have not been able to obtain the funding to conduct the expensive Randomized Clinical Trials (RCTs) to meet the criteria to be classified as an EBT. In fact, when reviewing the literature for a paper on best treatments for ethnic minorities (Burlew et al., 2010), we identified numerous promising substance abuse prevention and treatment interventions that clinicians currently cannot select for their settings because the interventions have not been subjected to RCTs. Instead, a disproportionate number of these projects may be financed locally or funded by SAMSHA where the emphasis on service rather than research makes it difficult to fund RCTs. To address the knowledge gap in understanding which generic and which culturally adapted interventions are most effective, we encourage the NIH to establish a mechanism to test the effectiveness of such interventions. The recent interest in funding comparative efficacy studies is certainly consistent with this direction. Moreover, recent concerns over the underrepresentation of ethnic minorities especially Blacks as NIH grant awardees (Ginther et al., 2011) is certainly related to the limited number of EBTs with demonstrated efficacy with specific racial ethnic minority groups.

SUMMARY AND CONCLUSIONS

A more culturally diverse society will require more than universalistic approaches to substance use treatment. The NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001) emphasize the responsibility of social workers and other practitioners to respond to this demand. Previous reviews suggest that EBTs are beneficial for ethnic minorities (Huey & Polo, 2008; Miranda et al., 2003). However, given convincing evidence that culturally adapting interventions can improve the outcomes for certain interventions, this article contributes to the development of effective culturally adapted interventions by discussing the available evidence on why, what, where, and when specifically to adapt generic substance abuse EBTs. This article also describes the currently available frameworks for cultural adaptation and reviews specific cultural adaptation approaches that illustrate the three most common strategies: community involvement, review of existing literature and research, and consultation from experts. However, the field will need to address a number of challenges to cultural adaptation such as the need for more research to identify the specific EBTs that warrant adaptation, the need to maintain the balance between fidelity and adaptation, the need for culturally competent research, and the need to consider intragroup diversity.