Adaptation of the Coping With Stress Course for Black Adolescents in Low-Income Communities: Examples of Surface Structure and Deep Structure Cultural Adaptations

Abstract

Black adolescents in low-income communities are at increased risk of developing mental health problems due to the impact of cumulative poverty-related stressors and racial discrimination, yet Black youth have relatively low rates of mental health service utilization, resulting in significant unmet need. The Coping With Stress (CWS) Course is an evidence-based, cognitive behavioral intervention that has been shown to reduce the incidence of anxiety, mood, and conduct problems among predominantly White samples, as well as Asian and Latinx youth. In the past 25 years since the CWS Course was introduced, Black adolescents have either been severely underrepresented or conspicuously absent from program evaluation research on the CWS Course, with few exceptions. The purpose of this article is threefold: (1) to justify the need for cultural adaptations to the CWS Course for Black adolescents from low-income communities, (2) to describe the scientific basis for the specific surface structure and deep structure modifications made to the culturally adapted version of the CWS Course, known as Resilient In spite of Stressful Events or RISE, and (3) to illustrate the deep structure adaptations with a vignette drawn from implementation of the RISE program with Black adolescents in a low-income, urban community.

Black adolescents in low-income communities are at increased risk of developing mental health problems due to the impact of cumulative poverty-related stressors (Devenish et al., 2017; Hurd et al., 2013; Simons et al., 2016) and discrimination (Schmitt et al., 2014; Seaton et al., 2008), yet Black youth have relatively low rates of mental health service utilization, resulting in significant unmet need (for a review, see Alegria et al., 2010). The Coping With Stress (CWS) Course (Clarke & Lewinsohn, 1995) is an evidence-based, cognitive behavioral intervention for adolescents at risk for depression initially developed with non-Hispanic White adolescents from suburban high schools and medical clinics in Portland, Oregon (Clarke et al., 1995; Clarke et al., 2001) and shown to reduce the incidence of anxiety, mood, and conduct problems among predominantly White samples, as well as Asian and Latinx youth (Clarke et al., 1995; Clarke et al., 2001; Marchand et al., 2010; Rohde et al., 2004). However, the program has had limited use with Black adolescents (for an exception, see Robinson et al., 2016), and cultural adaptations to the CWS Course have not been systematically examined to date. The purpose of this paper is to describe the scientific basis behind cultural adaptations to the CWS Course to enhance treatment engagement and reduce depressive symptoms and aggression among Black adolescents living in low-income, urban communities. The modifications to the CWS Course reflect surface structure adaptations, which involve “matching intervention materials and messages to observable, ‘superficial’ characteristics” of the youth, and, more importantly, deep structure adaptations, which involve “incorporating the cultural, social…and psychologic forces that influence” the mental health of Black youth in low-income communities (Resnicow et al., 2000, p. 271). Surface structure and deep structure adaptations have also been referred to as peripheral and core adaptations, respectively (Chu & Leino, 2017). This article will justify the need for cultural adaptations to the CWS Course, describe the scientific basis for the specific surface structure and deep structure adaptations made, and illustrate the deep structure adaptations with a vignette drawn from implementation of the culturally adapted program in a low-income, urban community.

A brief discussion of the social ecology of Black adolescents in low-income communities is necessary to understand the context within which the culturally adapted program was developed. Adolescents in the U.S. today face a host of stressors unique to their generation, including an increase in publicized incidents of police violence towards People of Color resulting in growing stress nationwide, as well as stress associated with mass shootings (American Psychological Association [APA], 2018, 2020). In fact, 56% of young people report experiencing stress “when considering the possibility of a shooting at their school” (APA, 2018, p. 2). For Black adolescents, the stressors common to their generation are compounded by their experience with discrimination stemming from structural racism, which is a pernicious feature of the lived experience of Black Americans of all ages (Pager & Shepherd, 2008; Seaton et al., 2008). Forty-six percent of Black older adolescents and emerging adults report significant stress from discrimination, higher than any other racial or ethnic group (APA, 2018), and research indicates that perceived discrimination is a causal factor that negatively impacts mental health (Douglass, Mipuri, English, & Yip, 2016; Schmitt et al., 2014). In addition, Black youth are 14 times more likely than White youth to live in neighborhoods with high childhood poverty (Drake & Rank, 2009), and children and adolescents exposed to poverty are vulnerable to a wide range of mental health problems due to the cumulative risks associated with poverty (Evans et al., 2013; McMahon et al., 2003). Community and familial poverty-related stressors, such as victimization, changes in household composition, and incarceration of family members, are associated with higher rates of conduct disorder, oppositional-defiant disorder, major depressive disorder, and dysthymia among youth (Tiet et al., 2001). In fact, a growing body of experimental research demonstrates that poverty has a causal effect on the social-emotional health of American children and adolescents (National Academies of Sciences, Engineering, & Medicine, 2019).

Justification for cultural adaptations to the CWS Course

The CWS Course is a group cognitive-behavioral intervention designed to prevent depressive symptoms among adolescents at increased risk of depression due to known risk factors (e.g., having a parent with depression or having subdiagnostic symptoms of a mood disorder), and it is one of relatively few evidence-based prevention programs specific to adolescents identified in the Institute of Medicine’s (2009) review of promising preventive interventions for youth mental health disorders. The original CWS Course (Clarke & Lewinsohn, 1995) consists of fifteen 45- to 60-minute sessions designed to be implemented in a school setting, either as its own class, as a supplement to a health class, or as an after-school group delivered 2 to 4 times a week. The initial sessions include psychoeducation on depression and its relationship to stressful situations, and in subsequent sessions group members learn to use cognitive restructuring techniques to modify irrational or negative self-statements and thoughts about others (Clarke, 2003; Clarke & Lewinsohn, 1995). Thus, the primary mechanism of change in the CWS Course is development of cognitive restructuring skills to modify irrational and unrealistic thoughts that promote and maintain negative emotions, such as depressed mood and irritability. The CWS Course is effective for adolescents in a variety of settings, including health clinics (Clarke et al., 2001), schools (Clarke et al., 1995; Hayes & Morgan, 2005), and juvenile detention centers (Rohde et al., 2004). Equally well supported is the 8-session second-generation version of the CWS Course (TEAMS/POD Intervention Team, 2003), abbreviated by the program developers for implementation in a national study, with sites in Nashville, Pittsburgh, Portland, and Boston (Garber et al., 2009). However, over the past 25 years in each of the afore-mentioned settings, Black adolescents were either severely underrepresented or conspicuously absent from evaluations of the CWS Course. For instance, early evaluations of the CWS Course often had so few Black participants that the specific percentage in the sample was not specified: only 7.5% of the adolescents in the original randomized, controlled trial of the CWS Course identified as being a member of a racial/ethnic group other than non-Hispanic White, and the disproportionately low percentage of People of Color continued in subsequent studies (e.g., 11.5% of the participants in Clarke et al., 2001). Even research evaluating the effectiveness of the CWS Course for adolescents from different racial/ethnic groups in the U.S. (Marchand et al., 2010) has excluded Black youth from analyses because the authors argued that there was inadequate statistical power for group comparisons, given the low number of Black adolescent participants (6.6% in Study 1 and 14.7% in Study 2).

Recently, the CWS Course has been adapted for use with Black adolescents from low-income families attending high school in Chicago (Robinson et al., 2015; Robinson et al., 2016). This adapted version of the CWS course, referred to as Adapted-CWS (A-CWS) and developed by Robinson and colleagues, “retains the original … theoretical framework [and] . . . incorporates culturally and environmentally sensitive topics into the existing CWS framework” (2016, p. 120), which is consistent with the concept of surface structure cultural adaptations (Resnicow et al., 2000). These surface structure adaptations include modifications typically made when transporting a program to a new context, such as changing the dialogue, graphics (e.g., cartoons), proper names (e.g., characters in examples), and cultural references in program materials (e.g., manuals, workbooks, handouts) to be more representative of urban, Black youth. Preliminary findings from a randomized controlled community trial of A-CWS showed that, relative to adolescents who received standard care from school staff, adolescents in the intervention group reported lower trait anxiety but no difference in suicidality at post-intervention; neither depressive symptoms nor aggression were evaluated in the preliminary studies of A-CWS (Robinson et al., 2015; Robinson et al., 2016). The surface structure adaptations made to A-CWS (Robinson et al., 2016) are a valuable first step toward adapting the CWS Course for Black adolescents from low-income, urban communities, but growing evidence suggests that it is deep structure adaptations that are likely to be most effective for these adolescents because deep structure adaptations incorporate the unique risk factors involved in the development of psychopathology among Black youth living in communities of concentrated poverty.

Several recent literature reviews indicate that culturally adapted interventions are superior to un-adapted interventions for People of Color (Hall et al., 2016; Soto et al., 2018; van Mourik et al., 2016) and that greater emphasis on deep structure adaptations addressing the underlying risk factors associated with a target community are warranted (Jones et al., 2018; van Mourik et al., 2016). Three meta-analyses of experimental and quasi-experimental studies of culturally adapted interventions targeting behavioral and emotional health outcomes in People of Color found that culturally adapted programs have higher effect sizes when compared to the original un-adapted programs (Hall et al., 2016; Soto et al., 2018; van Mourik et al., 2016). Most of the cultural adaptations in the primary studies examined in these meta-analyses involved what would be considered surface structure adaptations, or changes to peripheral components such as changing the language of the intervention from English to the preferred language of the target group, matching the race or ethnicity of the therapist with that of the clients, and modifying the images and content of program materials to be culturally congruent with the target population (Chu & Leino, 2017). However, in one quantitative synthesis of 18 randomized controlled trials examining culturally adapted group parent training programs for children from low socioeconomic backgrounds, van Mourik and colleagues (2016) identified a sufficient number of primary studies using deep structure adaptations to test whether the type of cultural adaptations (surface structure vs. deep structure) moderated treatment effects. Results indicated that parenting interventions for racial and ethnic minority families with deep structure adaptations had a significantly higher mean effect size (d = 0.54) when compared to interventions with surface structure adaptations (d = 0.24) and interventions with no reported adaptations (d = .10). The deep structure adaptations in the studies reviewed included content that addressed “cultural and contextual influences on parenting” within the Black community, such as racial socialization, family structure, and religious values (p. 101). The authors concluded that the most effective method of achieving cultural sensitivity and cultural effectiveness in parenting interventions for children is to employ deep structure adaptations. A qualitative research synthesis conducted by Gonzales et al. (2016) came to a similar conclusion after examining studies of cultural adaptations to evidence-based prevention programs targeting anxiety and depression among youth. The authors noted that, although the literature to date is limited, surface structure culturally adapted interventions for Black children and adolescents resulted in changes in anxiety and depression that were no different from the control group, suggesting that for Black youth “deep-level adaptations might be necessary as current findings [of surface structure adaptations] are not very encouraging” (p. 912).

Lau (2006) presents a useful framework for determining when cultural adaptations are warranted and for guiding the selection of specific deep structure adaptations based on unique processes contributing to the development of psychopathology in a cultural group. Lau argues that “adaptation may be warranted when there is evidence pointing to important variability across groups in (a) contextual processes influencing vulnerability to and protection from target problems and/or (b) response to common [evidence-based] strategies for the target problem” (p. 297). According to Lau, cultural adaptations should specifically address community contextual factors that differentially impact risk for development of presenting problems in a distinct population. For example, the Black Parenting Strengths and Strategies program, which is a cultural adaptation of the well-known Parenting the Strong-Willed Child Program, was specifically adapted to emphasize racial socialization practices, based on research indicating that parental racial socialization is a salient protective factor for Black children (Lau, 2006). The risk and protective factors unique to Black adolescents in the context of urban poverty have been described elsewhere in depth (see Devenish et al., 2017; Evans & Kim, 2013; Jones et al., 2020; Leventhal & Brooks-Gunn, 2000; McCrea et al., 2019; Santiago et al., 2016). The risk factor most relevant to this discussion of cultural adaptations to the CWS Course is disruption in the ability to cope with cumulative, uncontrollable poverty-related stressors, which places Black youth from low-income communities at significantly increased risk for both internalizing and externalizing disorders; the most relevant protective factors are strong family and peer relationships and adolescents’ orientation towards the future. Given that the original CWS Course does not reflect key risk and protective factors linked to the behavioral and emotional health of Black adolescents from low-income, high-stress neighborhoods, along with evidence that the original program has limited social acceptability among urban Black youth (Robinson & Case, 2002), a community-based participatory research process was utilized to identify culturally responsive, evidence-based adaptations informed by the cultural-contextual risks and strengths specific to these youth. This participatory process resulted in a culturally adapted version of the CWS Course called Resilient In spite of Stressful Events, or RISE (Clarke, 2020).

The community-based participatory process used to develop the RISE program spanned a 6-year period and involved community input at every stage. Adaptations were made to the CWS Course during the first 3 years (Clarke, 2011), followed by a 3-year period when the culturally adapted RISE program was evaluated in a community randomized trial (Clarke, Gallop, & Power, 2021). The adaptation process began with a series of focus groups comprised of high school students, community leaders, and youth program directors from a predominantly Black low-income, urban community. Results from the focus groups revealed several salient stressors (e.g., peer stress, exposure to violence, and financial strain) and critical program components, such as opportunities for youth to discuss personal experiences and engage in recreational activities, which were included in the first version of the RISE program. Subsequently, the second and third versions of RISE were developed with feedback from members of a Community Advisory Board and adolescents who participated in feasibility studies of the RISE program. During the feasibility study phase, after each RISE session, program staff rated participant engagement and adolescents completed a brief post-session telephone interview that included administration of the Children’s Intervention Rating Profile (CIRP; Elliott et al., 1986) and questions related to session content and process. As new qualitative and quantitative data were obtained from evaluations of each iteration of RISE, data were analyzed and interpreted in collaboration with community partners. Ultimately, the final version of the RISE program reflected both culturally responsive and scientifically grounded adaptations.

RISE is a 9-session manualized cognitive-behavioral preventive intervention (Clarke, 2020) adapted, with permission, from the 8-session version of the CWS Course (Clarke, 2003) and delivered in the context of an after-school program operating out of a public high school located in a large metropolitan area in the Northeast. A comparison of the RISE program content with the 8-session CWS Course content is presented in Table 1. RISE sessions are held weekly and led by trained graduate student co-leaders and undergraduate student program assistants attending a regional public university, under the supervision of a licensed psychologist. The program is designed to be delivered to adolescents in small groups of 8–12 youth, with a youth to program assistant ratio of 2:1. In addition to the weekly group sessions, which run for 1 hour and 45 minutes, youths are provided a full-day college tour to local universities and, at the conclusion of RISE, youths are typically referred to other community-based youth development programs. The scientific basis for the specific surface structure and deep structure cultural adaptations incorporated in RISE are described in depth below.

Table 1.

RISE Session Content Compared to CWS Course Session Content

Session Number	RISE Session Title	Rise Session Goals	CWS-8 Session Goals
1	Getting to Know Each Other	1. Introduce participants and staff. 2. Describe RISE schedule, guidelines, and housekeeping. 3. Review the importance of confidentiality. 4. Discuss what stress is and what it does to us. 5. Introduce the idea that how a person copes with the stress in their life relates to the direction their life is headed.	1. Get-acquainted activity 2. Stress and depression 3. Personal goals 4. Measuring your mood 5. Sharing activity
2	Resilient Role Models	1. Create group guidelines. 2. Learn about the life experiences of celebrities who were resilient in spite of stressful events. 3. Introduce the idea that thoughts, feelings, and outcomes in response to a stressful situation are all interrelated. 4. Introduce the director’s journal.	1. Guidelines for this group 2. Identifying negative thoughts 3. Sharing activity
3	Thinking About Your Thinking	1. Introduce the idea of monitoring your thoughts, or “thinking about your thinking.” 2. Identify discouraging versus encouraging thoughts. 3. Practice substituting realistic encouraging thoughts for discouraging thoughts in real life situations.	1. Identifying situations that make you feel sad or stressed 2. Increasing positive thinking 3. Sharing activity
4	Controlling Your Thinking	1. Learn to increase encouraging thoughts by recognizing the strengths others see in you. 2. Encourage students to think about the difference between problems that are a teen’s job to control and problems that are not a teen’s job to control. 3. Enable students to list stressors common in their lives and identify the controllable vs. uncontrollable aspects.	1. Practice identifying unrealistic thoughts 2. Changing these to realistic thoughts 3. Sharing activity
5	What I Can and Can’t Control	1. Practice making accurate appraisals about the controllable vs. uncontrollable aspects of common stressful situations. 2. Practice substituting encouraging thoughts for the uncontrollable aspects of situations.	1. Unrealistic thoughts about someone else may really be about yourself 2. Sharing exercise
6	Feel Better About What I Can’t Control	1. Continue to practice identifying uncontrollable aspects of stressful situations. 2. Learn to feel better about what you can’t control. 3. Identify healthy ways to help yourself feel better about things you can’t control.	1. A-B-C practice or sources of unrealistic beliefs 2. Problem solving 3. Sharing activity
7	Change What I Can Control	1. Introduce students to three problem-solving steps to help them handle the controllable parts of stressful situations. 2. Allow students to develop a RISE Above Stress skit, depicting healthy ways to cope.	1. Interrupting unrealistic thoughts 2. Using these skills in your life 3. Prompts or reminders 4. Sharing activity
8	Putting it All Together	1. Introduce students to three coping questions that can help them handle the uncontrollable and controllable parts of stressful situations. 2. Practice using the coping questions with common stressful situations. 3. Allow students to videotape their RISE Above Stress skit, depicting healthy ways to cope.	1. Emergency planning 2. Maintaining your gains 3. Questionnaires 4. Sharing activity
9	Saying Goodbye	1. Conclude the RISE Program with a concluding ceremony. 2. Allow students to view all of the videorecorded RISE Above Stress skits, depicting healthy ways to cope.

Surface Structure Cultural Adaptations

A variety of surface structure adaptations specific to program delivery were employed to strengthen adolescents’ engagement in the RISE program. For instance, in contrast to A-CWS, the RISE program is delivered in the context of an after-school program and draws youth from various schools and neighborhoods within the metropolitan area. After-school is an excellent setting for delivery of mental health programming for youth because it represents an informal community context, preferred by many Black Americans, and eliminates the potential for students to miss academic classes which is one of the most frequently cited drawbacks to school-based interventions (Frazier et al., 2007; Girio-Herrera et al., 2016). Also, in comparison to school-based programs, community-based prevention programs for low-income, urban youth produce stronger effects (Farahmand et al., 2012). To address practical barriers arising from attending an after-school program, RISE participants are offered tokens for transportation as well as a meal during the group session. Also, given that peer influence can promote positive adaptation among adolescents (Allen & Antonishak, 2008) and that peer and family support buffer Black adolescents from the negative effects of poverty-related stress (Hammack et al., 2004), RISE youth are encouraged to invite their siblings and peers to participate in the program with them. This increases youth engagement, capitalizes on family connections, which is an important strength within the Black community, and allows the program to target youth’s social ecology at the microsystemic level of the family and the peer group. Another surface structure modification relevant to the delivery of RISE is the targeted inclusion of undergraduate program assistants from diverse racial, ethnic, and socioeconomic backgrounds who are responsible for assisting group leaders in small-group activities and promoting adolescent engagement. The resulting diversity in RISE program staff allows adolescent participants to pair with RISE program assistants who share similar demographic characteristics, if that is the adolescent’s preference; this is noteworthy because a racial match between provider and client is one cultural tailoring approach that has empirical support, particularly among Black clients (Gonzales et al., 2017; Jones et al., 2018). Additionally, given that the college student program assistants attend a public university where approximately 30% of undergraduates identify as a first-generation college student, RISE program staff members often come from a similar social class and community background as the adolescent program participants, which builds a sense of comradery and shared experience.

In addition to adaptations to delivery, the RISE program includes several surface-level modifications to the content of the original CWS Course. Based on feedback from students and teachers that the CWS Course should include more culturally relevant material (Clarke, 2011; Robinson & Case, 2002), all examples, video clips, and cartoons in the RISE manual reflect themes consistent with Black urban adolescent life, including issues specific to their environment (e.g., community violence, police brutality, and financial strain) and issues specific to their developmental stage (e.g., conflict with romantic partners and parents). Another novel aspect of the RISE program based on the research literature, as well as youth self-reported preferences, is the addition of recreational activities. According to the broaden-and-build theory, emotions like joy and excitement, although short-lived, are more likely to result in an openness to new ideas and flexibility of thought (Frederickson & Branigan, 2005). By incorporating “loosen-up” activities at the start of each RISE session, as well as other activities throughout the program to promote enjoyment (e.g., meals, friendly competition, music, the college tour), the aim is to increase the likelihood of RISE participants engaging with the instructional material and considering ways to apply it to their own lives. An additional benefit of the recreational activities is that it increases adolescents’ interest and anticipation for each subsequent session, thereby enhancing program engagement. The inclusion of recreational activities in RISE is especially important given that youth in low-income families are significantly less likely than youth from families with greater discretionary income to participate in structured, supervised extra-curricular activities (Mahoney & Eccles, 2008). Finally, because a growing body of research shows that future orientation serves as an important protective factor for Black adolescents exposed to community violence (e.g., So et al., 2018; Stoddard et al., 2011), the adapted program encourages adolescents to consider their future selves and their long-term life goals. RISE emphasizes future orientation from the first session and builds upon this theme throughout the program (e.g., asking participants to consider whether their responses to stressful situation will help or hurt them in relation to reaching their long-term goals). The emphasis on future orientation is furthered by including a college tour and program staff who are role models for how to make it to and through college despite having limited financial resources (e.g., attending community college before transitioning to a 4-year college, being a commuter student).

Deep Structure Cultural Adaptations

RISE maintains the focus on cognitive restructuring that is the central mechanism of change in the original CWS Course, while simultaneously extending the theory of change to target an additional cognitive-behavioral skill, namely coping flexibility.¹ Coping flexibility is defined as “intraindividual variability in the deployment of diverse coping strategies and…the capacity to exhibit such variability in a way that fosters adjustment to life changes” (Cheng et al., 2014, p. 1582). Individuals who use coping strategies that fit with the demands of specific stressful situations are better adjusted overall (Cheng et al., 2014), and the ability to cope flexibly is of utmost importance in the context of low-income, urban communities where Black adolescents experience an array of chronic, cumulative, interrelated stressors. Moreover, a particularly debilitating aspect of the context of urban poverty is the presence of uncontrollable stressors. RISE trains youth to accurately distinguish the aspects of a stressful situation that are controllable from those that are uncontrollable and to select coping strategies that match their control appraisals.

The RISE program’s dual focus on cognitive restructuring and coping flexibility targets the deficits in coping skills that arise from Black adolescents’ experiences of living in adverse community contexts. The mechanisms targeted in the RISE program are based on the transactional model of stress and coping (Folkman, 1984), as well as the family process model of economic hardship and child adjustment (e.g., Elder et al., 1985; Masarik & Conger, 2017; Simons et al., 2016) and the adaptation to poverty-related stress model (Wadsworth et al., 2013), which extends the family process model. According to the latter two models, economic hardship in the broader community and within the family influence parenting processes, which in turn predict child coping processes and, ultimately, child adjustment (see Figure 1). The transactional model of stress and coping points to specific coping processes that are thought to be adaptive in the face of stress; whether a coping strategy is adaptive depends, in part, on the individual’s appraisal of the degree to which the situation is within their control. For example, if a young person uses problem-solving strategies to attempt to directly resolve a situation that is largely out of their control (e.g., parental divorce, police brutality), then those coping attempts are likely to lead to poor mental health outcomes. Conversely, if a young person resigns him- or herself to a situation that is, in fact, largely within their control (e.g., conflict with a friend) and does nothing to directly resolve it, that too can lead to poor mental health outcomes. In short, making accurate control appraisals and then fitting your coping strategies with those control appraisals is key (Clarke, 2006). The original CWS Course is like most cognitive-behavioral intervention programs for youth in that it fails to emphasize situational coping appraisals or the control-coping fit. In RISE, adolescents are taught to make accurate control appraisals in response to various stressful situations relevant to their daily lives and to match their chosen coping strategy with their control appraisal. Sessions 1–3 focus on cognitive restructuring, and Sessions 4–6 focus on coping flexibility. The focus of Sessions 6–9 is on integrating previously learned skills with problem-solving steps.²

Figure 1.

Theory-based Framework Underlying the RISE Program. Note. This model shows the modifiable risk factors involved in the relationship between economic hardship and the development of psychopathology among youth. The RISE program is designed to intervene in adolescents’ coping processes and ultimately reduce vulnerability to poverty-related stress by targeting cognitive restructuring skills and coping flexibility.

Coping flexibility is introduced in Session 4 when the RISE group leader acknowledges that just changing discouraging thoughts to encouraging thoughts (i.e., cognitive restructuring) is not always sufficient to help people to feel better about a stressful situation because there are situations that warrant directly changing the problem. Adolescents are taught that there are some stressful situations that they can change and some that they cannot change, either because they could not predict the situation or because they have very little control over the people or circumstances that are involved with the stressful situation. The RISE group leader then informs the group members that they will be practicing how to distinguish between the aspects of a problem that are their job to control and the aspects that are not under their control. In small groups, adolescents generate specific examples of stressful events that are common among their peers; typical examples include parents fighting, a friend betraying you, noise from sirens in the neighborhood at night, and failing grades. Each small group is then instructed to create three columns on a piece of paper and write the list of stressors in the center column. The other two columns on the paper are labeled “Parts of the problem that are my job to control or fix” and “Parts of the problem that are not my job to control or fix.” After the adolescents list the stressors and identify the controllable and uncontrollable aspects of the stressors, each small group selects one of their stressful situations to role-play for the entire RISE group. Following each role-play, audience members identify the controllable and uncontrollable aspects of the situation presented and group leaders facilitate a large group conversation about the accuracy of the adolescents’ control appraisals. The following vignette from Session 4 illustrates a large group discussion about control appraisals that was prompted by an adolescent sharing one example of a stressful situation discussed in the small group.

Youth 1: One of our stressful situations was your parents fighting. You can’t control what they’re fighting about, but you can address them.

Youth 2: But they might be fighting about you.

Leader: If they’re fighting about you, what part of it can you control?

Youth 2: Sometimes my sister likes to blame stuff on me, and then I get in trouble for it.

Youth 3: If your parents are fighting about you, it might be time for you to grow up and change your actions, or you need to talk to your parents about the problem that they have with you.

Youth 4: You go, girl!

Youth 2: You’re trying to call me immature, and I’m not!

Youth 4: You’re being immature now.

Youth 2: Don’t talk to me.

Leader: So [Youth 2], you’re the one who brought it up when you talked about parents fighting about you. You brought yourself into the situation, so are you comfortable talking about yourself?

Youth 3: Yes, I am!

Leader: Ok, so the question I have for you is, “What about your parents fighting about you do you have control over?”

Youth 2: I can try… I can change my behavior.

Leader: Ok. So, you can change your behavior. Now what about it do you not have control over?

Youth 2: I don’t have control over them fighting in general!

Leader: I heard that. How many people agree that, generally speaking, you don’t have control over how angry your parents get at each other, whether or not they fight, what kind of mood they’re in? [Multiple participants raise their hands.]

Youth 2: Sometimes it’s about how my mom handles different situations in general. It’s not always about me.

Leader: What [Youth 2] is saying is correct, as far as there are parts about what our parents do that we do not have control over. But she also said…how many in here heard her say that the part she can control is her behavior? Anybody hear that? [Multiple participants raise their hands.] Everybody in this room has parents or caregivers who are going to be upset with them at some point. Everybody is going to have problems with their parents, and there’s parts of it we can control and parts of it we can’t, and the point of this activity is for each of you — no matter how good you think you are and no matter how bad people think you are — to think about what you can control in your life and what you can’t. And that’s what’s important before you think about how to cope with something.

Later in the same session, after additional discussion and practice making control appraisals, the following interaction occurred in response to an example about an adolescent being unfairly treated by a foster parent.

Leader: You can’t control what you’re born into. But what do you have control over?

Youth 2: What you come out of it as! [Leader smiles and nods at Youth 2]

Youth 5: Oh, girl, that’s philosophical! [Group members clap for Youth 2]

Youth 6: What’d she say?

Leader: She said, “You do have control over what you come out of it as.” So, you might not have control over what you come into, but you do have control over what you come out as.

At the end of Session 4, the message of the day is shared with the adolescents: “For every problem, there are some things you can control and some things you can’t—so first figure out the difference, then figure out what to do.” This message draws attention to the importance of making accurate control appraisals, a central component of coping flexibility. In subsequent sessions, adolescents learn to match appropriate coping strategies to the controllable versus uncontrollable aspects of situations, which is a second component of coping flexibility. For instance, in Session 5, adolescents practice applying cognitive restructuring specifically for the uncontrollable aspects of stressful situations, and in Session 6 youth identify healthy behaviors to help themselves feel better about what they cannot control.

Conclusion

Currently, there are very few published examples of deep structure adaptations of evidence-based interventions targeting depressed mood and aggression among Black adolescents. In a recent review of peer-reviewed cultural adaptation studies published between 1994–2014, Chu and Leino (2017) identified 45 studies that explicitly described the research-based adaptations made to mental health interventions for racial and ethnic minority groups, and only 2 of the 45 studies focused on Black adolescents. Making cultural adaptations to existing evidence-based interventions is an efficient method of developing culturally responsive programs that can meet the unmet mental health need of Black adolescents from low-income, urban neighborhoods. Consistent with Chu and Leino’s (2017) finding that most adaptations add culturally relevant content while retaining core components tied to the theory of change, RISE maintains an emphasis on core components in the original CWS Course, such as cognitive restructuring, but RISE also includes surface structure adaptations to delivery and content, as well as deep structure additions based on the cultural-contextual risks for Black youth in low-income communities. The surface structure and deep structure adaptations incorporated into RISE have resulted in a promising culturally adapted program. Preliminary evidence of the RISE program’s effectiveness has been found in a pilot community trial in which 67 adolescents were randomly assigned to the intervention group or the waitlist control group. Results demonstrated high program acceptability on the CIRP (M = 32.0, SD = 3.7; CIRP total score ranges from 7 – and high youth engagement (71% of participants attended 6 or more weeks of programming). Moreover, adolescents assigned to RISE were rated by their caregivers on the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) as having significantly fewer externalizing behavior problems (CBCL Externalizing T-score) and fewer total problems (CBCL Total T-score) at posttest in comparison to adolescents assigned to the waitlist group (Clarke et al., 2021). Of note, there was no significant group difference in caregiver ratings of internalizing behavior problems from pre- to posttest, suggesting that there is still room for enhancing the immediate effects and potentially the long-term impact of the RISE program.

Clinicians interested in delivering culturally responsive, evidence-based interventions to Black adolescents in low-income communities should follow the three pillars of evidence-based practice in psychology by integrating “the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA, 2006, p. 273). It is critical to integrate all three components when developing an intervention from the ground up and when adapting one. Typically, when cultural adaptations are made, clinical expertise and community preferences are prioritized, but the scientific basis for cultural adaptation is often neglected. This paper provides an example of the ways in which the best available research can inform cultural adaptations to create a program that is both socially valid and effective for a high-risk population. Ultimately, it is the integration of all three pillars of evidence-based practice that will contribute to greater acceptability and portability of a variety of evidence-based interventions to promote the mental health of Black adolescents in low-income neighborhoods across the U.S.

Highlights.

• Few evidence-based interventions have been culturally adapted for Black adolescents

• A culturally adapted version of the evidence-based Coping With Stress Course shows promise

• Surface structure and deep structure cultural adaptations are recommended