Person-Centered Cultural Assessment Can Improve Child Mental Health Service Engagement and Outcomes.

OBJECTIVE: Disparities in child mental health service engagement suggest traditional evidence-based practices do not properly consider cultural and contextual factors relevant for marginalized families. We propose a person-centered approach to improve the cultural responsiveness of services. Preliminary research supports broadening standard assessments to include a person-centered evaluation of patient cultural factors, however, controlled studies have not been conducted in the context of children's mental health care. METHODS: Participants included families (N = 89; 89% racial/ethnic minority) receiving services for child externalizing problems. Prior to intake, caregivers were randomized to receive either Assessment as Usual (AAU) or AAU augmented with the Cultural Formulation Interview (CFI+AAU), a brief caregiver assessment of cultural factors affecting their child's problems and family help-seeking. RESULTS: Implementation data showed strong provider fidelity and clinical utility. Following assessments, CFI+AAU caregivers (relative to AAU caregivers) reported feeling better understood by their provider, and providers reported better understanding CFI+AAU families' values. Caregiver satisfaction was rated highly overall, yet providers reported being more satisfied with the assessment when the CFI was incorporated. Engagement outcomes found CFI+AAU families were significantly more likely than AAU families to subsequently complete the first phase of treatment. Further, among families receiving services in Spanish, CFI+AAU, relative to AAU, was associated with significantly higher treatment attendance, homework completion, and treatment response. CONCLUSIONS: The results underscore the utility of incorporating a brief cultural assessment in pretreatment assessments. To improve the cultural responsiveness of services, efforts may do well to promote the uptake of person-centered approaches such as cultural assessment into usual care. Registered at clinicaltrials.gov (NCT03499600).

Examining the effectiveness of the Cultural Formulation Interview with young children: A clinical illustration.

After years of extensive research, the Cultural Formulation Interview (CFI) was released in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Similar to its predecessor, the Outline of the Cultural Formulation (OCF), the CFI aims to refine the psychiatric assessment process by systematically examining cultural factors. However, in contrast to the OCF which employs open-ended questions, the CFI uses a semi-structured interview format. Unfortunately, children and adolescents have only been included in a handful of OCF and CFI studies, which raises questions about their applicability with youth, particularly young children (11 years or younger). In this article, we start examining the usefulness of the CFI with young children and propose recommendations to enhance its benefits by suggesting the development of a supplementary module specifically designed for young children. These ideas are illustrated with the assessment of a 6-year-old boy of Somali descent.

Ideas para desarrollar una psicoterapia congruente con las características culturales argentinas: aplicando el modelo de la consonancia cultural / Ideas to develop a psychotherapy congruent with argentinian cultural characteristics:applygin the cultural match model

Muchos modelos psicoterapéuticos estudian al individuo en ausencia de su contexto y características culturales. Lamentablemente, esta carencia limita la eficacia de estos modelos psicoterapéuticos en la Argentina. Estas deficiencias son particularmente pronunciadas en la medida que estos modelos difieren de las características típicas de la Argentina. En este trabajo describimos el modelo de la consonancia cultural para incluir la contribución de las variables culturales y el contexto cultural para la generación de una psicoterapia con apoyo empírico que refleje las características argentinas. Para lograr este fin comenzamos por describir tres características típicas de la Argentina. Luego presentamos dos ejemplos clínicos que describen cómo beneficiarse de las variables culturales y el contexto cultural en el proceso psicoterapéutico. Concluimos con algunas ideas para implementar adaptaciones de tratamientos psicológicos al contexto local argentino

Many psychotherapeutic models study the individual in the absence of their cultural characteristics and contexts. Unfortunately, this lack of information limits the effectiveness of these psychotherapeutic models in Argentina. These deficiencies are particularly pronounced since these models are based on settings that differ from the typical characteristics of Argentina. In this work, we describe the cultural match model that includes the contribution of cultural variables, and the cultural context. Our aim is to generate an empirically supported psychotherapy that reflects the Argentinian background. To achieve this goal, we begin by describing three typical characteristics of Argentina. We then present two concrete clinical examples that illustrate how to benefit from the cultural variables and the cultural context in the psychotherapeutic process. We conclude with some ideas to implement adaptations of psychological treatments to the local Argentinian context

Intersectionality in psychotherapy: The experiences of an AfroLatinx queer immigrant.

Culturally responsive and racially conscious psychotherapeutic work requires that therapists recognize the ways clients are impacted by their multiple marginalized identities and by systems of oppression (e.g., racism, ethnocentrism, sexism, heterosexism, and nativism). Attending exclusively to clients' marginalized identities (i.e., weak intersectionality) may drive therapists to only focus on internal, subjective, and emotional experiences, hence, missing the opportunity to consider and address how multiple sociostructural dimensions (i.e., strong intersectionality) may be impacting the client's presenting problems. Alternatively, focusing solely on the impact of sociostructural dimensions on the lives of clients may miss the more nuanced and variable individual personal experiences. In this article, we highlight the challenge of maintaining a culturally responsive and racially conscious stance when considering multiple marginalized identities, overlapping systemic inequities, and how both affect clients' lives and experiences. The case of an AfroLatinx queer immigrant is presented to illustrate some of the challenges and opportunities while simultaneously considering (a) the client's multiple marginalized identities, (b) the way clients are impacted by systemic oppression, and (c) integrating the client's personal experiences and narratives in psychotherapy. (PsycINFO Database Record

Patient-Provider Therapeutic Alliance Contributes to Patient Activation in Community Mental Health Clinics.

Patient activation, often conceptualized as an individual trait, contributes to mental health outcomes. This study assessed the relational contributors to activation by estimating the longitudinal association of patient-provider communication and two factors of therapeutic alliance (agreement on tasks/goals and bond), with patient activation. Participants were patients (n = 264) from 13 community-based mental health clinics across the United States. In multivariate models, controlling for patients' individual and clinical characteristics, the task/goal factor of therapeutic alliance emerged as a significant and independent predictor of greater change in patient activation scores. Improving patient activation may require addressing patient-provider interactions such as coming to collaborative agreement on the tasks/goals of care.

Activation, self-management, engagement, and retention in behavioral health care: a randomized clinical trial of the DECIDE intervention.

IMPORTANCE: Given minority patients' unequal access to quality care, patient activation and self-management strategies have been suggested as a promising approach to improving mental health care. OBJECTIVE: To determine whether the DECIDE (Decide the problem; Explore the questions; Closed or open-ended questions; Identify the who, why, or how of the problem; Direct questions to your health care professional; Enjoy a shared solution) intervention, an educational strategy that teaches patients to ask questions and make collaborative decisions with their health care professional, improves patient activation and self-management, as well as engagement and retention in behavioral health care. DESIGN, SETTING, AND PATIENTS: In this multisite randomized clinical trial performed from February 1, 2009, through October 9, 2011 (date of last follow-up interview), we recruited 647 English- or Spanish-speaking patients 18 to 70 years old from 13 outpatient community mental health clinics across 5 states and 1 US territory. A total of 722 patients were included in analyses of secondary outcomes. INTERVENTIONS: Three DECIDE training sessions delivered by a care manager vs giving patients a brochure on management of behavioral health. MAIN OUTCOMES AND MEASURES: Primary outcomes were patient assessment of activation (Patient Activation Scale) and self-management (Perceived Efficacy in Patient-Physician Interactions). Secondary outcomes included patient engagement (proportion of visits attended of those scheduled) and retention (attending at least 4 visits in the 6 months after the baseline research assessment), collected through medical record review or electronic records. RESULTS: Patients assigned to DECIDE reported significant increases in activation (mean ß = 1.74, SD = 0.58; P = .003) and self-management (mean ß = 2.42, SD = 0.90; P = .008) relative to control patients, but there was no evidence of an effect on engagement or retention in care. CONCLUSIONS AND RELEVANCE: The DECIDE intervention appears to help patients learn to effectively ask questions and participate in decisions about their behavioral health care, but a health care professional component might be needed to augment engagement in care. DECIDE appears to have promise as a strategy for changing the role of minority patients in behavioral health care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01226329

A culturally competent relaxation intervention for Latino/as: assessing a culturally specific match model.

In this study, we explored 2 questions: (a) Consistent with the cultural match theory (CMT), did treatment adherence and outcome improve as discrepancies between the cultural features of an anxiety treatment and patient characteristics decreased, and (b) In agreement with the specific therapy ingredient model (STIM), did the psychotherapeutic outcomes of a Culturally Competent Relaxation Intervention (CCRI) designed to reduce anxiety more effectively reduce anxiety rather than depression symptoms? The CCRI includes allocentric (the tendency to define oneself in relationship to others) relaxation interventions, while traditional relaxation strategies employ idiocentric (the tendency to define oneself in isolation from others) relaxation interventions. The CCRI was assessed with 44 Latino/a adults of low socioeconomic backgrounds. The results supported 2 hypotheses: (a) Based on the CMT, a relationship was found between participants' levels of allocentrism and their consequent levels of treatment adherence, and (b) Consistent with the STIM, treatment adherence on the CCRI was correlated with reductions in anxiety, but not with depressive symptoms. These findings are discussed with a focus on future efforts to create culturally competent interventions.

A content analyses of guided imagery scripts: a strategy for the development of cultural adaptations.

This paper proposes a first step in deciding whether it is necessary to develop a cultural adaptation by comparing the cultural characteristics of an intervention with the same characteristics of a specific group. Larger cultural differences suggest a greater need to conduct a cultural adaptation. This recommendation stems from the cultural match theory (CMT) which, explains that therapeutic outcomes increase as interventions are more similar to the cultural characteristics of specific treatment groups. However, the CMT has rarely been tested, partly because strategies to effectively measure the cultural characteristics of an intervention are still lacking. This article addresses this gap by assessing two dimensions of the self-orientation relevant to cultural adaptations, namely, idiocentrism--the tendency to define oneself in isolation from others--and allocentrism--the tendency to define oneself in relationship to others--through a content analysis of guided imagery scripts. Two independent evaluators analyzed 123 guided imagery scripts (published during 1989-2008) using 6 theoretically derived categories to analyze idiocentrism versus allocentrism. Results indicated that idiocentric elements were 1.5 to 52.3 times more frequently used than were allocentric ones. The implications of these findings for the development of culturally adapted interventions are discussed.

A culturally competent asthma management intervention: a randomized controlled pilot study.

BACKGROUND: Despite significant medical advances, many ethnic and racial minority children who live in inner cities continue to experience disproportionately high levels of asthma morbidity and mortality compared with white children. As a result, a growing number of psychosocial asthma management interventions are being developed to address their needs; however, only a few of these interventions have incorporated cultural variables into their treatments and have had their efficacy evaluated. OBJECTIVE: To examine the efficacy of the Multifamily Asthma Group Treatment (MFAGT), designed to enhance asthma management and reduce emergency department (ED) visits among African American and Hispanic families. METHODS: Twenty-four African American and Hispanic families who have children with asthma were randomly assigned to either the MFAGT or the Standard Psychoeducational Asthma Intervention. Differences in the number of ED visits and the level of asthma management in both groups were compared 1 year before and 1 year after the intervention. In addition, these groups were contrasted to a control group that did not receive any psychoeducational intervention. RESULTS: The MFAGT was significantly (P = .04) more effective than the Standard Psychoeducational Asthma Intervention and the control in decreasing ED visits and increasing parental asthma knowledge. CONCLUSIONS: These preliminary results suggest that the MFAGT is efficacious in enhancing asthma management and in reducing ED visits in inner-city African American and Hispanic children from a lower socioeconomic background.

Culturally sensitive guided imagery for allocentric Latinos: A pilot study.

The Culturally Competent Relaxation Intervention (CCRI) was developed and assessed with 25 Latino adults. In contrast to traditional psychotherapeutic and relaxation interventions, which are highly influenced by individualistic/idiocentric (the tendency to define oneself in isolation from others) assumptions, the CCRI was designed according to an allocentric self-orientation (the tendency to define oneself in relationship with others), which is prevalent among Latinos. This pilot study found preliminary evidence suggesting that participants who were more allocentric had higher levels of treatment adherence and, contrary to what was expected, idiocentric levels were not inversely related with treatment adherence. In addition, as hypothesized, it was found that higher levels of treatment adherence were related to reductions of anxiety symptoms. These findings are consistent with the predictions of the cultural match theory, which proposes that patients adhere and benefit more from interventions that fit their own cultural characteristics. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

At the crossroads: managed mental health care, the ethics code, and ethnic minorities.

Mental health clinicians are facing an increasing number of ethical problems related to the delivery of managed mental health care services to ethnic minorities. The authors argue that (a) economic pressures have led to the development of the managed health care movement; (b) the combination of such economic pressures and the development of that managed care movement have influenced the promulgated ethical standards of the American Psychological Association; and (c) those influences may have a negative impact on the mental health services available to ethnic minority individuals and communities. The authors review some of the specific potential threats to mental health services for minorities in the face of such health management policy and psychologists' professional standards.