Using Evidence Based Using Evidence Based Interventions with Culturally Interventions with Culturally

Diverse Children and Diverse Children and Families: Evidence and Families: Evidence and

Strategies for Engagement Strategies for Engagement

David G. Stewart, Ph.D.David G. Stewart, Ph.D.Seattle Pacific UniversitySeattle Pacific University

ObjectivesObjectives

Rationale for attending to diversity in EBP Rationale for attending to diversity in EBP implementationimplementation

Methods for maintaining adherence and fidelity Methods for maintaining adherence and fidelity AND engagementAND engagement Culturally competent collaborationCulturally competent collaboration Cultural Hypothesis TestingCultural Hypothesis Testing MI strategiesMI strategies

Case ExamplesCase Examples ProgrammaticProgrammatic IndividualIndividual

All published reports 1986-2000

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

Pe

rce

nt

Re

pre

se

nte

d

African-American Hispanic or Latino Asian/Pacific Islander American Indian/Alaska Native

Ethnic Group

2001 Surgeon General Report on Mental Health: Ethnic Representation in Randomized Clinical Trials for Bipolar Disorder, Schizophrenia, ADHD and Depression

Percentage of All Clinical Trial Participants(N=10,000)

Percentage of Clinical Trial Participants whereEthnicity was Identified (n=5,009)

Percentage in the U.S. Population

DisproportionalityDisproportionality

State of Washington

King County

JRA Statewide

JRA from King

County

White (non Hispanic) 79% 73% 54% 30% African American 3% 5% 18% 44%

Youth of Color 21% 27% 46% 70%

•African American (70%)

•White (21%)

•Hispanic

Mexican American

Puerto Rican

Peruvian

•Native American

•African

Eritrean

Ethiopian

Somali

Kenyan

•Samoan

•Tongan

•European

Russian

Bosnian

•Korean

•Vietnamese

•Cambodian

•Thai

Ethnic/ Cultural Characteristics ofClients Served 1998-2004 (N=195)

•Biracial

•Multiracial

•Gay

•Lesbian

•Bisexual

•Transgendered

Determining Fit of ESTs to Diverse Determining Fit of ESTs to Diverse ClientsClients

Are language, culturally specific variants Are language, culturally specific variants available?available?

Does EST have external /ecological validity?Does EST have external /ecological validity?

Has EST been developed with a Has EST been developed with a representative sample?representative sample?

Does diagnostic specific EST address cultural Does diagnostic specific EST address cultural variants in diagnosis?variants in diagnosis?

Does the EST include orientation/engagement Does the EST include orientation/engagement strategies?strategies?

Principles of Culturally Principles of Culturally Competent InterventionCompetent Intervention

Cultural Sensitivity

Cultural Competence

Cultural Specificity

Continuum of Addressing Diversity

Culturally Competent Practices  

Eight practices based on strategies developed by Bernal, et al. (1995) to promote culturally competent interactions. The principles are designed to be measurable by an objective rater.

1.Use language that enhances comfort and understanding. Avoid use of jargon or “loaded terminology.”

 

2. Acknowledge and use similarities and differences between individuals to shape and enhance the relationship. Culture is a central aspect of our assessment and intervention. The therapist’s culture as it relates to the process of engagement, clinical effectiveness and retention in treatment must be included early in the therapeutic process. Clients must be given an opportunity to discuss their feelings about the therapist’s culture (race, gender, SES, etc.). When clients are uncomfortable in even discussing differences or similarities, the therapist will raise and test hypotheses about his/her cultural impact with supervisors and colleagues.

3. Encourage ethnic/cultural symbols, concepts, sayings, stories as part of the dialogue.

The therapist who has genuine knowledge of a client’s cultural experience will use elements of that culture in creating therapeutic metaphors, examples and throughout the therapeutic dialogue. Therapists will also elicit this material from clients by asking about topics such as, family stories and multigenerational parenting practices. A therapist may also use language, symbols and stories from his own background to enrich the therapeutic dialogue. 

4. Demonstrate knowledge of and respect for cultural values and practices.  The therapist is aware of cultural norms in a variety of contexts including: personal space, time orientation, gender roles, generational roles, dress, emotional expression and religion. The therapist gains credibility by accepting these values and avoids making unnecessary judgments based on culture-bound behavior.

5. Set collaboration goals that are consonant with culture and context:  Any conflict between therapeutic needs and cultural norms is a topic of active discussion and problem solving.  

6. Support values and strengths from culture of origin. Strong religious affiliation, support of extended family, resilience and humor are examples of the types of cultural strengths to be utilized and enhanced.

7. Adapt methods to culture.  Bernal, et al. (1995) describe specific techniques that culturally competent therapists use to enhance existing treatment models these include: "modeling" to include culturally consonant traditions; "cultural reframing" of problems as partly reflecting economic and social realities; cultural hypothesis testing; use of genograms; "cultural migration/change dialogue"

8. Consider cultural context in implementation. All aspects of treatment specifically address the context of culture and social conditions on the client. Key factors include; societal pressures/conditions; social supports and relationship to community; economic and social context of intervention; ethnic labeling/disproportional sanctions; stress of migration or acculturation.

Bernal G, Bonilla J, Bellido C (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology. 23(1): 67-82.

Thought children want independence before ready.My children have seen too much sex on TV/movies.I thought my children not receiving good education.My children haven't respected my authority as should.My children have gotten bad school reports/grades.Thought about son/daughter living independently.My children have talked about leaving home.I thought my children used illegal drugs.My children influenced by bad friends.Difficult to decide how strict to be with children.

Hispanic Stress Inventory: Hispanic Stress Inventory: Parenting FactorParenting Factor

Cervantes, Padilla & Salgado de Snyder (1991)Cervantes, Padilla & Salgado de Snyder (1991)

Since I don't know English, hard interacting with others.I felt pressured to learn English.Thought I'd be deported if went to social/govt. agency.Due to poor English people treated me badly.Due to poor English, hard dealing with daily situations.I feared consequences of deportation.I felt guilty leaving family/friends in home country.Felt never regain status/respect I had in home country.I've been discriminated against.I've been questioned about my legal status.Haven't forgotten war deaths of friends/family.Haven't forgotten last few months in my home country.

Hispanic Stress Inventory: Hispanic Stress Inventory: Immigration FactorImmigration Factor

Cultural Hypothesis Testing (Stephen Lopez)

Make an informed guess as to possible cultural factors affecting treatment

Gather evidence through observation, questioning & consultation

Intervene Appropriately

Gather evidence of effectiveness of the intervention

Motivational Interviewing as a Motivational Interviewing as a Culturally Competent PracticeCulturally Competent Practice

• Evidence of increased effectiveness in Evidence of increased effectiveness in ethnic minority populationsethnic minority populations

• Inherent client-centered and directive Inherent client-centered and directive approachapproach

• Culturally specific adaptations Culturally specific adaptations

• Flexibility in implementation within or Flexibility in implementation within or before other EST’sbefore other EST’s

• Directly addresses ambivalence Directly addresses ambivalence

Here are some of the ideas Here are some of the ideas behind MI… behind MI…

1. Motivation for change honors the wisdom 1. Motivation for change honors the wisdom within the client instead of trying to force a within the client instead of trying to force a therapist’s wisdom upon a client. therapist’s wisdom upon a client.

2. The client is seen as a person rather than a 2. The client is seen as a person rather than a problem. The client identifies and processes problem. The client identifies and processes his or her own feelings about change. Some his or her own feelings about change. Some tribes take this level of respect to new heights tribes take this level of respect to new heights and call clients by their clan relation such as and call clients by their clan relation such as sister, uncle, etc. sister, uncle, etc.

Here are some of the ideas Here are some of the ideas behind MI… behind MI…

3. The counselor provides humble, respectful, 3. The counselor provides humble, respectful, and active guidance in helping the client and active guidance in helping the client examine and move forward with their feelings examine and move forward with their feelings about change. about change.

4. Persuasion is not an effective method 4. Persuasion is not an effective method because trying to convince others to change because trying to convince others to change often invites them to argue against change. often invites them to argue against change.

Here are some of the ideas Here are some of the ideas behind MI… behind MI…

5. The counseling style is peaceful and draws the 5. The counseling style is peaceful and draws the wisdom out from inside of the client. wisdom out from inside of the client.

6. Readiness to change is not steady. Instead, it 6. Readiness to change is not steady. Instead, it changes depending on the client’s internal and changes depending on the client’s internal and external environments (i.e. social relationships, external environments (i.e. social relationships, job status, financial status, family and friends, job status, financial status, family and friends, community). community).

7. The therapeutic relationship is more of a 7. The therapeutic relationship is more of a partnership, rather than an expert talking to a partnership, rather than an expert talking to a patient. patient.

Venner, K.L., Feldstein, S.M. & Tafoya, N. (2006). Venner, K.L., Feldstein, S.M. & Tafoya, N. (2006). Native Native American motivational interviewing: Weaving Native American and American motivational interviewing: Weaving Native American and western practiceswestern practices. Albuquerque: Authors. Albuquerque: Authors

Measuring Confidence to make a Change Measuring Confidence to make a Change

1. “On a scale of 0 – 10, where 0 is not at all 1. “On a scale of 0 – 10, where 0 is not at all confident and 10 is extremely confident, how confident and 10 is extremely confident, how confident are you that you could make a change confident are you that you could make a change in (specific behavior) now? in (specific behavior) now?

2. “What makes you choose (number client chose) 2. “What makes you choose (number client chose) rather than a 0?” rather than a 0?”

““What does it mean to be a (number client chose)? What does it mean to be a (number client chose)?

3. “What would it take to bump you up a few 3. “What would it take to bump you up a few notches to a (choose a number two or three notches to a (choose a number two or three higher than originally given)? higher than originally given)?

Exploring Pros and Cons to Exploring Pros and Cons to Elicit Change Talk Elicit Change Talk

Goals: To provide an opportunity for Goals: To provide an opportunity for your clients to actively discuss how your clients to actively discuss how they feel about a specific behavior. they feel about a specific behavior.

To provide the counselor an opportunity to To provide the counselor an opportunity to understand the client’s point of view about understand the client’s point of view about the pros and cons of the behavior, to the pros and cons of the behavior, to reinforce change talk, and to support the reinforce change talk, and to support the client. client.

Here are some of the ideas Here are some of the ideas behind MI… behind MI…

1. Motivation for change honors the wisdom 1. Motivation for change honors the wisdom within the client instead of trying to force a within the client instead of trying to force a therapist’s wisdom upon a client. therapist’s wisdom upon a client.

2. The client is seen as a person rather than a 2. The client is seen as a person rather than a problem. The client identifies and processes problem. The client identifies and processes his or her own feelings about change. Some his or her own feelings about change. Some tribes take this level of respect to new heights tribes take this level of respect to new heights and call clients by their clan relation such as and call clients by their clan relation such as sister, uncle, etc. sister, uncle, etc.

Here are some of the ideas Here are some of the ideas behind MI… behind MI…

3. The counselor provides humble, respectful, 3. The counselor provides humble, respectful, and active guidance in helping the client and active guidance in helping the client examine and move forward with their feelings examine and move forward with their feelings about change. about change.

4. Persuasion is not an effective method 4. Persuasion is not an effective method because trying to convince others to change because trying to convince others to change often invites them to argue against change. often invites them to argue against change.

Here are some of the ideas Here are some of the ideas behind MI… behind MI…

5. The counseling style is peaceful and draws the 5. The counseling style is peaceful and draws the wisdom out from inside of the client. wisdom out from inside of the client.

6. Readiness to change is not steady. Instead, it 6. Readiness to change is not steady. Instead, it changes depending on the client’s internal and changes depending on the client’s internal and external environments (i.e. social relationships, external environments (i.e. social relationships, job status, financial status, family and friends, job status, financial status, family and friends, community). community).

7. The therapeutic relationship is more of a 7. The therapeutic relationship is more of a partnership, rather than an expert talking to a partnership, rather than an expert talking to a patient. patient.

Adapted from: Rollnick, S. & Miller, W. R. (1995) What is motivational interviewing? Adapted from: Rollnick, S. & Miller, W. R. (1995) What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334 Behavioural and Cognitive Psychotherapy, 23, 325-334

  

Engagement, Accountability and

Cultural Competence in the MST/FIT Model

Cultural Competence

1. Interventions are designed to empower families to intervene in multiple systems, including ones that may be perceived as coercive or punitive

2. Interventions are provided by therapists who are :Culturally Competent and oftenCulturally Matched

3. Interventions are designed that are respectful of and consistent with the cultural values of the family and community.

4. Cultural strengths are recognized and developed as keys to change

Teen

Peers

School

Caregivers

Neighborhood

Siblings

Social-Ecological Model

Teen Positive Behavior

CaregiversHigh MonitoringConsistent DisciplineLow ConflictExpressed Warmth

PeersPositive PeersPeers are involved in + activities

SchoolAttached to schoolAchieving-moving toward graduation

NeighborhoodMultiple adult(+) models - Recreational ActivitiesJobs/ training - Religious/Spiritual Guidance

Keys to EngagementKeys to Engagement

Treatment team responsible for engagement and Treatment team responsible for engagement and provide services unconditionallyprovide services unconditionally

Therapists are strength-focusedTherapists are strength-focused

Family members full collaborators; therapists align Family members full collaborators; therapists align with parentswith parents

Services individualized and comprehensiveServices individualized and comprehensive

Services provided in natural ecology (i.e., family Services provided in natural ecology (i.e., family home)home)

Creating an Environment of Creating an Environment of Alignment and EngagementAlignment and Engagement

   

“My family and the therapist were honest and straightforward with each other.”

 “The sessions were lively and energetic.”

 “Family members were not engaged in power struggles

with the therapist.” 

“My family and the therapist had similar ideas about ways to solve problems.”

“Family members and the therapist agreed upon the goals of the sessions.”

“A lot was accomplished during the therapy sessions.”

“My family and the therapist worked together effectively.”

Alignment and Engagement

Case PresentationCase PresentationH., a 15 y.o., Eritrean-American maleH., a 15 y.o., Eritrean-American male

Marijuana Dependence, Ecstacy & Alcohol Marijuana Dependence, Ecstacy & Alcohol UseUse

Oppositional Defiant DisorderOppositional Defiant Disorder

History of thefts, domestic violence, History of thefts, domestic violence, truancy and noncompliance with probationtruancy and noncompliance with probation

Attending alternative school due to Attending alternative school due to disruptive behavior and truancydisruptive behavior and truancy

At Risk Youth Petition At Risk Youth Petition

Case PresentationCase Presentation

Lives with Mother and 2 brothersLives with Mother and 2 brothers Brother # 1 age 18, in college headed for Brother # 1 age 18, in college headed for

dental schooldental school Brother #2 age 16, incarcerated for arsonBrother #2 age 16, incarcerated for arson Parents divorced, father in town, alcoholic, Parents divorced, father in town, alcoholic,

little contactlittle contact

Cultural Hypothesis Testing (Stephen Lopez)

Make an informed guess as to possible cultural factors affecting treatment

Gather evidence through observation, questioning & consultation

Intervene Appropriately

Gather evidence of effectiveness of the intervention

Cultural Role Hypothesis: Mother’s cultural beliefs about parenting and women’s roles preclude taking strong stance with defiant teenage son

•Discuss with Mother in individual session•Migration Dialogue•Meet with cultural consultant•Discuss with older son •Partially Confirmed

•Engage older brother, uncle and community members to assist mother in parenting

•Therapy strategies with Mother to reframe some cognitions around past events and parenting and learn to tolerate the distress of parenting 3 teenage sons alone

•Engagement of family improved•H. became involved in positive community activities•Brother increased activity with H.

Ethnic Identity Development Hypothesis: H. desperately wants to identify with American culture and takes on an exaggerated role modeled by peers (gang-wannabes)

•Discuss with family in session•Discuss with cultural consultant•Confirmed: Youth is struggling with issues of identity development and acculturation

•Provide positive African American role models

•Exit alternative school and enroll in public school with diverse African American peer group

•Enroll in activities to foster positive identity development- Martial arts, African language course, African American History group

•Dissociated from negative peers•Successful enrollment in public school•More integrated identity development