Cultural Issues in Mental Health Treatment

Handbook of Advances in Culture and

Psychology Volume Six

Edited by

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Michele J. Gelfand Chi-yue Chiu Ying~yi Hong

I OXFORD

fnternatfonal Auodatlon for Cross-Cultural Pr councries. Published in the United States of America by Oxford University Press 198 Madison Avenue. New York, NY 10016, United States of America.

©Oxford University Press 2016 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press. or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to Jhe Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquin1r. Cataloging·in·Publication data is on file at the Library of Congress Handbook of Advances in Culture and Psychology ISSN 2155-2622 ISBN 978-0- 19-045885- 0 (hbk.) ISBN 978-0-19-045886- 7 (pbk.)

CH APT ER 3

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Cultural Issues in Mental Health Treatment NOLAN ZANE ANO CINDY Y. HUANG

Abstract Mental health disparities exist for ethnic minority populations that include lower rates of service use and poorer treatment outcomes due to inaccessible and/or ineffective treatment. Ethnic minority clients often see therapists or are administered treatments that do not properly consider their cultural and linguistic backgrounds or life circumstances. Racial/ethnic differences also interact with cultural factors (such as help-seeking beliefs) to inHuence mental health outcomes. Researchers have adapted mental health treatments for specific minority populations; however, adaptations vary in form, content, and the manner by which they are implemented. This chapter summarizes a program of research that examines disparities in mental health treatments and outcomes for ethnic minority groups and identifies critical cultural factors associated with treatment processes and outcomes, with a particular focus on Asian American mental health. It also reviews work in the cultural adaptation of empirically supported treatments and presents the challenges associated with this research. Key Words: culture, mental health. treatment, culturally informed, disparity, Asian American •

I. INTRO DUCTION Decades of research have consistently found disparities in the utilization and quality of mental health treatment for ethnic minority populations (Smedley, Stith. & Nelson, 2003; US Department of Health and Human Services, 200i). Various presidential commissions have documented unmet mental health needs of members of ethnic minority groups such as African Americans, American 113

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Indians, Asian Americans, and Latino/as (e.g.• Commission on Mental Health to the Surgeon General, 1978; President's New Freedom Commission, 2003). The commissions concluded that these disparities in mental health treatment were not due to racial and ethnic differences in rates of psychopathology but rather to inaccessible and ineffective treatment. For instance, ethnic minority clients often saw therapists or were administered treatments that did not properly consider their lifestyles, cultural and linguistic backgrounds, and life circumstances. In this chapter, we summarize a program of research dedicated to examining the disparities in mental health treatments and outcomes for ethnic minority groups, with a particular focus on Asian American mental health. We start by providing an overview of our research identifying the ethnic and cultural issues relevant to mental health treatments, followed by a discussion of the challenges in this research. Next, we discuss our model. the proximaldistal framework. and its corresponding studies as .a guiding framework for this research. We move into research on culturally adapted mental health treat· ments with an analysis on the existing ways in which treatments are adapted, and present our model for conducting empirically based cultural adaptations in mental health treatments. We conclude this chapter with a discussion of future directions in this field of research.

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II. ETHNIC AND CULTURAL ISSUES IN M ENTAL HEALTH TREATM ENT Compared to their representation in the US popuilation, ethnic minority groups have been found to either overuse (e.g., African American) or underuse (e.g., Asian American) mental health services (Sue. 1977; Sue, Fujino, • Hu, Takeuchi, & Zane, 1991). A large-scale study examining the utilization rates of more than 13,000 Asian American, African American, and Latino clients in the Los Angeles County mental health system over a 5-year period found that 20.5% of African Americans were in th(~ mental health system, compared to their county representation of only 12.8% (Sue et al.. 1991). Conversely, Asian American and Latino clients made up 3.13 and 25.5% in the mental health system, while their populations in the county were much higher (8.7% and 33.7%, respectively}. Similar patterns in service use of 14,000 clients in the Seattle mental health system were found in a previous study (Sue, 1977). These patterns are also found in t reatment research with ethnic minority youth (Ho, Liang. Martinez, Huang, & Yeh, 2006), suggesting that the disparities in mental health service use are pervasive and have family and community influences.

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The disparities in mental health use for immigrant populations such as Asian Americans warrant special attention because many of these ethnic minority individuals may not be familiar with mental health care and treatment. Asian Americans are the fastest growing population in the United States-this group alone increased by 43% from the year 2000 to 2010 (Hoeffel, Rastogi, Kim, & Shahid, 2012). If these trends continue, the disparities experienced by Asian Americans and other immigrant groups may become an increasing public health problem. The diversity of these populations also poses a unique challenge for mental health researchers. For instance, Asian Americans are considered to be one racial/ethnic group, but a large majority of Vietnamese, Chinese, and Asian Indians were born outside of the United States, whereas Japanese and Hawaiians tend to be born in the United States (Zane, Hall, Sue, Young, & Nunez, 2004). This leads to a variety of different considerations for researchers, since non-US-born Asians may have linguistic and cultural challenges (e.g., difficulty acculturating or adapting to mainstream US culture) that may not be present for US-born Asians. The notion that Asian Americans and other immigrant groups underuse mental health services may be premature if most of the underutilization is accounted for by those with less severe problems. Unfortunately, our findings suggest this is not the case. In a nationally represented sample of Asian American adults, we examined only those individuals with diagnosable mental disorders to determine whether people clearly in need of mental health care actually sought treatment {Meyer, Zane, Cho, & Takeuchi, 2009). We found that even among individuals with diagnosable problems, Asian Americans still used mental health services at about half the rate as individuals with mental health problems in the general population (283 vs. 54%). We also found that US-born Asian American participants were almost 15 times more likely to use mental health services than non-US- born participants. In addition, those born outside of the United States were more likely to use mental health services if they immigrated at a younger age. English-language fluency moderated the influence of the use of alternative services (e.g., services performed by a religious/spiritual leader, doctor of oriental medicine, chiropractor) on mental health service use. Asians with poor or fair English proficiency who sought alternative services were less likely to use mental health services. However, individuals who were proficient in English and used alternative services were almost seven times more likely to also use mental health services. Thus, cultural factors, such as acculturation, beliefs about mental health problems, and stigma may affect the disparity in mental health use rates found in the United States.

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A. Variations in Treatment Processes and Outcomes Ethnic and cultural group variations also are found in psychotherapy processes and outcomes (Zane et al., 2004). In particular, studies have determined that ethnic minority clients experience more negative treatment outcomes than their White counterparts even when they are using mental health services. Researchers have investigated this issue by examining premature termination, which occurs when clients drop out of treatment prior to completing treatment and before any substantial benefits have been received from psychotherapy. Premature termination is often used as an indication of treatment outcome because it serves as a proxy for client satisfaction. That is, a client who is not satisfied with their treatment and services is more likely to drop out before the treatment ends or is deemed completed by the therapist. The length of treatment (i.e., dosage, or the number of treatment sessions a client received), therefore, also serves as an indirect indicator of treatment outcome. Studies indicate that clients receiving mental health services reported more improvement in their symptoms if they had a higher number of therapy sessions (Lambert, Hansen, & Finch, 2001). Numerous studies have documented the higher dropout rates of minorities compared with White clients. As early as the 1970s, research has shown that ethnic minorities have higher rates of dropout, and that this dropout occurs early in outpatient treatment in the public mental health system (Sue, 1977). Clients in other service settings show similar rates of premature termination. For instance, African American veterans in the Veterans Administration had higher rates of early termination when they were paired with White therapists (Rosenheck, Fontana, & Cot trol, 1995). In this study, 29% of the African American veterans paired with a White therapist failed to return for a second session, and even when they continued treatment, they averaged 17 sessions compared with the 25 sessions of African Americans paired with an African American therapist Similarly, Latino and Asian American clients who did not speak English as a primary language were more likely to prematurely drop out if their therapists were White (Russell, Fujino, Sue, Cheung, & Snowden, 1996; Sue et al., 1991; Yeh, Eastman, & Cheung, 1994). More recent studies have found similarly disparate rates. Owen, Imel, Adelson, and Rodolfa (2012) studied a sample of over 300 adults receiving mental health services at \ a university counseling center and examined the unilateral dropout rates (i.e., client dropping out of services without informing their therapist) of th~se clients. They found that ethnic minority clients were significantly more likely to drop out prematurely than their White counterparts. Approximately 36.83 of

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ethnic minority clients unilaterally dropped out of treatment compared with only 24.9% of the White clients (Owen et al., 2012). The studies on premature dropout and treatment duration can provide evidence only suggestive of disparities in quality of care, as these factors are proxies for actual treatment outcomes. Few studies have examined racial/ ethnic disparities in treatment outcomes for clients who remain in treatment. In one such study, we assessed the treatment outcomes of White and Asian clients at a community mental health center during the first and fourth t reatment sessions (Zane, Enomoto, & Chun, 1994). Based on client selfreport and therapist-rated outcome measures, Asian clients had poorer treatment outcomes than their White counterparts after controlling for severity of problems at pretreatment. Specifically, Asian American clients were more depressed and hostile after four sessions of treatment. Asian American clients also were less satisfied with progress in treatment, their therapists, the overall service received, access to services, and the fee charged than White American clients. In other words, Asian American clients were less satisfied with all aspects of their treatment experience compared with their White American counterparts. There also was a tendency for therapists to evaluate Asian clients as having lower levels of psychosocial functioning than White clients after short-term treatment. Note that these d!isparate outcomes occurred after only a short period of treatment-four sessions. These disparities in treatment outcomes are concerning; they highlight the need to better understand how ethnic minority clients respond to mental health treatments. Mental health treatment research has long established ways to better ensure positive outcomes for clients through empirically supported treatments (ESTs), which have been shown to be superior in efficacy compared with a placebo or another treatment through well-designed experiments and clinical trial research (Chambless & Hollon, 1998). Howe~r. relatively little research (i.e., clinical trial studies) has focused on establishing ESTs for ethnic minority populations. In their investigation into ESTs for ethnic minority populations, Chambless and colleagues (1996) were unable to find a single study that implemented the rigorous standards needed to establish efficacy for treatments. The US Surgeon General (2001) also reported that research involving controlled clinical trials used to generate professional treatment guidelines did not conduct specific analyses for any minority group. Specifically, approximately 10,000 participants have been included in randomized clinical trials since 1986. For studies involving about half of these participants, no information on race or ethnicity was provided.

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For another 7% of participants, studies only reported the general designation of "non-White." Studies for the remaining 47% of participants included very few minorities, and not a single study analyzed the efficacy of the treatment by ethnicity or race. Findings from a more recent study seem to indicate that even the most current treatment research programs are not producing "best available evidence" on minority populations or issues. A study was conducted involving 379 clinical trials funded by the National Institute of Mental Health and published between 1995 and 2004 in five leading mental health journals (Mak. Law. Alvidrez, & Perez-Stable, 2007). Findings revealed that less than half of the studies provided information on the specific ethnic composition of their samples. Among those that specified their ethnic composition, most ethni~ minority groups were underrepresented, notably Asian Americans, Hispanics, and N~tive Americans. White Americans continued to be t he most sampled ethnic group in clinical trials, with 613 representation in studies that provided specific ethnic information. Moreover, few studies analyzed for ethnic or cultural effects. Research on ESTs with children and adolestakeholders of that cultural or ethnic group. According to Kazdin (1977), m adaptation is only successful if there is empirical evidence demonstrating ;ocial validity by the specific cultural or ethnic group for whom an adapta:ion was made. Similar to our proximal-distal model, there are three different \reas social validity can be established: (1) clients from a particular cultural ~roup perceive the clinical problem as significant or important; (2) clients view ·he procedures and/or attitudes of an intervention as culturally acceptable or 1ppropriate; or (3) the treatment goals, or targeted outcomes for change, must >e valued by the clients and considered to be functional and important.

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Plans are underway to pilot test an adapted intervention of CBT for depression among Asian Americans. Given the previous research and following the CPA, the adaptation uses face-saving strategies to enhance self-disclosure and client engagement as well as specific CBT procedures for pain management to address the somatic tendencies of Asian American clients. For the former, the adaptation focuses on reframing personal issues into solving specific problems as opposed to reducing "personal" symptoms or managing a "personal" disease (Littlejohn & Domenici, 2006). In this way, the orientation fosters demonstrations of mastery and competence that can enhance face restoration and minimize further face loss. For the latter, the adaptation capitalizes on empirically supported CBT procedures such as relaxation training and cognitive restructuring to reduce catastrophizing over somatic symptoms so that the intervention directly addresses the somatic tendencies of Asian American clients.

B. Determining Cultura l Intervention Effectiveness The CPA approach provides researchers with guidelines to systematically adapt interventions for ethnic minority and cultural groups. A different but related issue in cultural adaptations is the testing of these adaptations. More specifically, how do researchers determine whether or not an adapted intervention is more effective than a noncultural intervention? The traditional method of determining treatment effectiveness involves the comparison of outcomes of a non cultural intervention with the outcomes of a cultural intervention. If the outcome of the cultural intervention is the same as the noncultural intervention, the results would be considered null and the researchers would claim the cultural intervention to be ineffective. However, the null findings may in fact suggest treatment effectiveness-if a cultural intervention is found to treat a problem as well as a noncultural intervention, that is evidence that (1) the intervention is effective, and (2) this intervention should be selected for use with the intended ethnic/cultural group because it has the added benefits of being culturally congruent and relevant. To further highlight this point, if a CBT that has been developed or adapted for Asian Americans is found to be just as effective as a traditional CBT designed without a specific target population, the adapted CBT should be selected for use with Asian American clients because it is just as effective and it is socially valid. In this case, researchers should be looking for equivalent findings between cultural and noncultural interventions rather than for cultural "" interventions to outperform noncultural interventions. In these outcome studies, testing for statistical equivalence would be appropriate.


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VII. CONCLUSIONS AND FUTU RE DIRECTIONS IN CULTURAL AND INTERVENTION RESEARCH The field of cultural and intervention research has made significant progress in the last few decades. Much more is known today about ethnic and cultural group differences, and the knowledge of which cultural factors and cultural variations are important in treatment processes and outcomes has expanded dramatically. There is also growth in the number of empirically supported treatments for ethnic minority groups, with many researchers developing and adapting interventions to be culturally informed. Despite these accomplishments, challenges remain in this research, which serves as a guide for the future direction in this field of research. One of the major challenges in cultural intervention research continues to be the dearth of theoretical models that provide a way of conceptualizing adaptations for ethnic minority populations. For instance, Kazdin's model of social validity has motivated researchers to assess for significance and relevance in mental health treatments, and well-validated measures on treatment acceptability have been developed (Reimers et al., 1998; Reimers & Wacker, 1988). Yet, few studies are using this model in their adaptations of interventions for cultural and ethnic minority groups and therefore do not collect or present social validity data as part of their adaptation process. Many studies continue to rely solely on focus group data and fail to collect experimentally rigorous data to inform their adaptations. Researchers need to begin to implement systematic ways of conductingjntervention research. This challenge is not limited to adaptation intervention research. Researchers whose goals are to identify cultural factors in mental health can use the proximal-distal and social validity models to help conceptualize and test their hypotheses on how ethnic minority clients can benefit from adapted or orthodox treatments. There is also argument in the field about whether cultural competence in clinical training is more critical in treating ethnic minority groups than adapting interventions. Some claim it is more relevant and important for clinicians to change the approach to their treatment with specific clients, as opposed to changing the treatment protocol. These issues are exacerbated by the difficulty of operationalizing cultural significance (e.g., how the intervention "fits" or is culturally appropriate for a given group). Gallimore and colleagues (1993) proposed defining cultural significance and relevance by matching the adaptations to people's activity settings. This is only one way of defining cultural significance, and more work on

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this area will help to ensure more empirically grounded research is conducted with cultural groups. Researchers need to provide more empirical evidence that adaptations are needed in cultural interventions with ethnic minority populations. One of the side effects of the growing recognition of cultural differences in intervention research is that adaptations and changes are often assumed necessary, rather than proven necessary. This has led some researchers to neglect the step of presenting adequate evidence to show that adaptations are needed such as by presenting empirical evidence that certain aspects of a treatment are not socially valid for a particular cultural group. Those working in this field must take a step back and reestablish the empirical support for culturally informed, adapted interventions. This must be done at all levels of this research, starting with the identification of relevant cultural factors in mental health and determining cultural and ethnic group differences in treatment outcomes, especially as these findings will inform and provide evidence for adaptations. fo conclusion, the challenges that are still present in this field of research are useful in informing the future directions researchers can take to improve cultural intervention research. The CPA shows promise as a systematic guideline for approaching cultural and intervention research. It provides steps that take researchers through variable selection, defining cultural significance, and establishing social validity. The CPA is also not limited to adaptation of treatment protocols. These guidelines also can be used to conduct basic research, such as exploring new theoretical conceptualizations of change for ethnic minority groups and investigating cultural issues in treatment-related processes and outcomes. In an applied setting, the CPA can be used to adapt a therapist's approach of treatment with a client. The critical process approach embeds empirically supported benchmarks throughout the entire cultural adaptation process, which will hopefully contribute to the development of more evidence-based as well as culturally informed interventions for ethnic minority clientele.

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