Culturally Responsive Cognitive Behavioral Therapy for Ethnically Diverse Populations.

Cognitive behavioral therapy (CBT) is often referred to as the "gold standard" treatment for mental health problems, given the large body of evidence supporting its efficacy. However, there are persistent questions about the generalizability of CBTs to culturally diverse populations and whether culturally sensitive approaches are warranted. In this review, we synthesize the literature on CBT for ethnic minorities, with an emphasis on randomized trials that address cultural sensitivity within the context of CBT. In general, we find that CBT is effective for ethnic minorities with diverse mental health problems, although nonsignificant trends suggest that CBT effects may be somewhat weaker for ethnic minorities compared to Whites. We find mixed support for the cultural adaptation of CBTs, but evidence for cultural sensitivity training of CBT clinicians is lacking, given a dearth of relevant trials. Based on the limited evidence thus far, we summarize three broad models for addressing cultural issues when providing CBT to diverse populations.

The Immigrant Paradox in the Problem Behaviors of Youth in the United States: A Meta-analysis.

This meta-analysis synthesizes the empirical data on problem behaviors among foreign- (G1) and U.S-born (G2+) youth and explores the effects of immigrant status on youth internalizing and externalizing problems. A random effects meta-regression with robust variance estimates summarized effect sizes for internalizing and externalizing problems across 91 studies (N = 179,315, Mage  = 13.98). Results indicated that G1 youth reported significantly more internalizing problems (g = .06), and fewer externalizing problems than G2+ youth (g = -.06). Gender and sample type moderated the effects. The findings provide a first-step toward reconciling mixed support for the immigrant paradox by identifying for whom and under what conditions the immigrant experience serves as a risk or protective factor for youth.

Worse for girls?: Gender differences in discrimination as a predictor of suicidality among Latinx youth.

INTRODUCTION: Gender and ethnic differences exist in suicidal ideation, plan, and attempt among adolescents in the U.S. However, limited research has used theoretically-informed approaches to integrate how cultural and classic risk factors together account for suicide-related pathways among vulnerable populations. Informed by the interpersonal theory of suicide, the present cross-sectional study examined gender differences in the association between a cultural (i.e., discrimination) and classic (i.e., depressive symptomatology) risk factor, and suicidality among youth of Latin American heritage. METHODS: A total of 390 Latinx adolescents (ages 13-18; 50% female) attending a high school in Southern California, U.S.A. completed a series of questionnaires that included measures of depressive symptoms, suicidality (including ideation, past attempts, and likelihood of future behavior), perceived discrimination, and demographics. RESULTS: We found that discrimination was associated with increased suicidality among Latinx adolescents. The discrimination-suicidality association was stronger for girls versus boys, such that girls who experienced greater discrimination demonstrated the highest levels of suicidality. Although depression was also significantly associated with suicidality, the discrimination x gender interaction was found above and beyond the main effect of depressive symptomatology and covariates. Additional analyses revealed significant gender and moderation effects only for suicidal ideation and not for attempts. CONCLUSIONS: These findings indicate that the relationship between discrimination and suicidality (particularly ideation) is more pronounced for Latinx girls than boys. This study also highlights the importance of drawing on theory-driven and culturally informed work that incorporates classic and cultural correlates of suicidality among diverse subpopulations.

Evidence-Based Psychosocial Interventions for Ethnic Minority Youth: The 10-Year Update.

This is the official update on the status of evidence-based psychosocial interventions for ethnic minority youth. Compared to a decade ago, there has been expansion of well-designed intervention studies, growth in the number (not type) of interventions meeting evidence-based criteria, and greater focus on testing ethnicity/race moderator effects. In terms of standard of evidence, 4 psychosocial interventions are now well-established and 10 are probably efficacious or possibly efficacious, with most protocols drawing on cognitive and behavioral change procedures and/or family systems models. Yet the research literature remains mostly focused on testing interventions with European Americans (White Caucasians), and little to no progress has been made in testing the effects of interventions with Asian American or Native American youth. Knowledge of the effects of cultural tailoring on program engagement, outcomes, and mechanisms of change remains scant.

A Preliminary Investigation of Ethnic Differences in Resistance in Multisystemic Therapy.

Therapy process research suggests that an inverted U-shaped trajectory of client resistance, referred to as the struggle-and-working-through pattern, predicts positive treatment outcomes. However, this research may lack external validity given the exclusive focus on European Americans. This preliminary study explores differences in resistance patterns in a sample of African American and European American juvenile drug offenders and their families (n = 41) participating in Multisystemic Therapy. Resistance was coded from session recordings at the beginning, middle, and end of treatment. There were significant ethnic differences in (a) mean resistance at midtreatment, (b) resistance trajectories, and (c) predictive relationships between resistance trajectories and criminal desistance. Notably, a negative quadratic (i.e., inverted U-shaped) resistance trajectory was more characteristic of European Americans who desisted from crime, whereas a positive quadratic (U-shaped) resistance pattern was more characteristic of African Americans who desisted. There was no relationship between resistance trajectory and later drug abstinence (i.e., cannabis). Within the context of evidence-based therapies, core treatment processes may vary significantly as a function of client ethnicity. We recommend that clinical scientists make efforts to test for ethnic differences in treatment process so that therapies like Multisystemic Therapy can be understood in a more comprehensive and nuanced manner.

Ethnic differences in response to directive vs. non-directive brief intervention for subsyndromal depression.

OBJECTIVE: Analog research suggests that directive interventions might increase treatment engagement for non-symptomatic Asian American (AA) students; however, no studies have assessed whether directiveness improves therapy processes or clinical outcomes for AAs with mental health symptoms. This study tested the comparative efficacy of brief directive vs. non-directive intervention for AAs and European Americans (EAs) with subsyndromal depression. METHOD: Participants were randomly assigned directive, non-directive, or cultural values interview conditions, and assessed three times over six months. Directive and non-directive treatment involved meeting with a therapist for a single, 20-minute session to receive psychoeducation and personalized feedback on depressive symptoms and coping strategies. Cultural values participants also met with a therapist. RESULTS: Although results were mixed for the overall sample, directive treatment was generally superior to non-directive treatment and cultural values at addressing depressive symptoms, coping behavior, and working alliance. Ethnicity did moderate treatment effects for some outcomes, but in an unexpected manner. At six-month follow-up, the directive intervention was more effective than cultural values at reducing depressive symptoms for AAs; however, the cultural values condition was more effective than the non-directive intervention at reducing depressive symptoms for EAs. CONCLUSION: Mixed evidence was found for directiveness as an Asian-specific treatment enhancement. Clinical or methodological significance of this article: This article adds to a complicated body of research and clinical work aiming to inform best practices for ethnic minorities. We found some evidence that a directive therapeutic style may be a "culturally invariant" clinical technique that could be beneficial to Asian American and European American populations alike. Yet, other findings suggest that directiveness might be uniquely advantageous for Asian Americans, particularly for long-term improvement of depressive symptoms.

Internet-delivered eating disorder prevention: A randomized controlled trial of dissonance-based and cognitive-behavioral interventions.

OBJECTIVE: The current study evaluated two web-based programs for eating disorder prevention in high-risk, predominantly ethnic minority women. METHOD: Two hundred and seventy-one women with elevated weight concerns were randomized to Internet dissonance-based intervention (DBI-I), Internet cognitive-behavioral intervention (CBI-I), or no intervention (NI). Both interventions consisted of four weekly online sessions. Participants were assessed at pre- and post intervention. Outcome measures included eating pathology, body dissatisfaction, dieting, thin-ideal internalization, and depression. RESULTS: At postintervention, DBI-I and CBI-I led to greater reductions in body dissatisfaction, thin-ideal internalization, and depression than NI. In addition, CBI-I was effective at reducing dieting and composite eating pathology relative to NI. No outcome differences were found between the active conditions. Moderation analyses suggested that both active conditions were more effective for ethnic minorities than Whites relative to NI. DISCUSSION: Results suggest that both DBI-I and CBI-I are effective at reducing eating disorder risk factors in a high-risk, predominantly minority population relative to no intervention.

Motivational Interviewing to prevent dropout from an education and employment program for young adults: A randomized controlled trial.

This study tested the efficacy of Motivational Interviewing for improving retention at a "second chance" program in the United States for unemployed young adults who had not graduated high school (ages 18-24; 60% male). We investigated how Motivational Interviewing effects might be mediated by change talk (i.e., arguments for change) and moderated by preference for consistency (PFC). Participants (N = 100) were randomly assigned to (1) Motivational Interviewing designed to elicit change talk, (2) placebo counseling designed not to elicit change talk, or (3) no additional treatment. Motivational Interviewing sessions increased change talk, but did not increase program retention or diploma earning. PFC was a significant moderator of Motivational Interviewing's impact on program retention; Motivational Interviewing was most effective at increasing 8 week retention for high PFC participants, and least effective for low PFC participants. These results suggest that Motivational Interviewing could be a useful tool for improving retention in education and employment programs, but clinicians should be attentive to how participant characteristics might enhance or diminish Motivational Interviewing effects.

The contribution of cultural competence to evidence-based care for ethnically diverse populations.

Despite compelling arguments for the dissemination of evidence-based treatments (EBTs), questions regarding their relevance to ethnically diverse populations remain. This review summarizes what is known about psychotherapy effects with ethnic minorities, with a particular focus on the role of cultural competence when implementing EBTs. Specifically, we address three questions: (a) does psychotherapy work with ethnic minorities, (b) do psychotherapy effects differ by ethnicity, and (c) does cultural tailoring enhance treatment effects? The evidence suggests that psychotherapy is generally effective with ethnic minorities, and treatment effects are fairly robust across cultural groups and problem areas. However, evidence for cultural competence is mixed. Ethnic minority-focused treatments frequently incorporate culturally tailored strategies, and these tailored treatments are mostly efficacious; yet support for cultural competence as a useful supplement to standard treatment remains equivocal at best. We also discuss research limitations, areas for future research, and clinical implications.

Assessing the Feasibility of Peer Coach Training for Disruptive Middle School Youth: A Mixed Methods Pilot Study.

In U.S. schools, disruptive behavior is by far the primary reason for disciplinary referrals, including suspensions and expulsions. School-based interventions targeting disruptive behavior usually position struggling youth as treatment recipients and neglect the psychosocial benefits of helping others. In this mixed methods pilot study, we evaluate the preliminary feasibility and acceptability of Peer Coach Training (PCT), a novel, school-based intervention for youth referred for disruptive behavior that deemphasizes the youth's existing problems and focuses instead on training youth to help their peers. We used quantitative and qualitative methods to evaluate the feasibility and acceptability of PCT on two cohorts of disruptive youth (N = 9) in an urban middle school in Southern California. Youth and teachers completed assessments at baseline, post-treatment, and three-month follow-up. At posttreatment and follow-up, youth reported significant reductions in externalizing problems, as well as reductions in conduct problems, attention problems, and aggressive behavior; in contrast, teacher ratings yielded null findings. Qualitative interviews revealed that youth and teachers observed positive changes in peer interactions, self-confidence, and classroom participation efforts. Youth satisfaction data indicated that youth enjoyed participating in PCT and would highly recommend it to their friends. Results from this pilot evaluation suggest that training youth to help their peers is an appealing, feasible, and promising strategy for reducing disruptive behavior, however, controlled trials are needed to provide evidence for treatment efficacy.

Advances in the adaptation and implementation of evidence-based interventions for historically marginalized groups.

This collection of six articles showcases innovative approaches to adapting and deploying evidence-based interventions with individuals from historically marginalized groups to advance mental health equity. The field of cultural adaptation has matured beyond initial questions about whether specific culturally adapted interventions work, and must now adopt designs that can yield generalizable knowledge concerning how and under what circumstances such adaptations can promote improved engagement and effectiveness with underserved groups. Crucial to this goal is identifying the target mechanisms presumed to underlie poorer clinical and engagement outcomes among minoritized groups that must be addressed by the adaptation. Furthermore, contributors have gone beyond adaptations to EBI therapeutic content and processes, to the mobilization of implementation strategies that increase the reach and impact of EBIs outside conventional service settings. Our featured investigators have also illuminated critical modifications to the entire research enterprise to center community needs in the conduct of intervention research with historically marginalized groups. We are grateful for the opportunity to highlight these contributions spanning intervention science, adaptation science, and implementation science in Behaviour Research and Therapy.

Applying ecological systems theory to juvenile legal system interventions outcomes research: a measurement framework.

Intervention research and development for youth in the juvenile legal system (JLS) has often focused on recidivism as the primary outcome of interest. Although recidivism is an important outcome, it is ultimately a downstream marker of success and is affected by changes in other domains of youths' lives (e.g., family and peer relations, neighborhood safety, local and state-level policies). Thus, the present manuscript proposes the application of ecological systems theory to selecting outcomes to assess intervention effects in JLS intervention research to better capture proximal and distal influences on youth behavior. To that end, we first provide an overview of the strengths and limitations of using recidivism as an outcome measure. Next, the current application of social ecology theory to existing research on both risk and protective factors of JLS involvement is discussed, as well as existing work on assessing social-ecological domains within intervention studies. Then, a measurement framework is introduced for selecting pertinent domains of youths' social ecologies to assess as intervention outcomes, moderators, and mediators. To facilitate this, we provide examples of concrete constructs and measures that researchers may select. We conclude with potential new avenues of research to which our proposed framework could lead, as well as potential limitations of implementing our framework.

Recruitment and Feasibility of Hair Cortisol Collection in a Sample of Ethnically and Sexually Diverse, Low-Income Adults: A Qualitative Community-Partnered Participatory Research Study.

The current study describes how a community-partnered participatory research (CPPR) model was used to enhance hair cortisol research engagement among low-income adults of diverse ethnicities and sexual and gender identities. Participants' reported motivations and concerns surrounding providing a hair sample are also described. Participants from a larger longitudinal study were invited to provide a hair sample and/or complete acceptability interviews. Results indicated that 71% of all persons (N=133) contacted participated in the current study, of whom 82% provided hair samples. Several themes emerged from the interviews indicating that participants were motivated to provide a hair sample due to internal and external factors; however, concerns about mistrust of research remained. Thus, collecting biospecimens in research with underserved groups requires careful consideration of benefits and risks to the individual and their communities. Our results provide guidelines for engaging low-income racially/ethnically and sexually diverse community members in biospecimen research to understand stress-health relationships.

Culturally adapted versus standard exposure treatment for phobic Asian Americans: Treatment efficacy, moderators, and predictors.

This study is a 6-month follow-up of a randomized pilot evaluation of standard one-session treatment (OST-S) versus culturally adapted OST (OST-CA) with phobic Asian Americans. OST-CA included seven cultural adaptations drawn from prior research with East Asians and Asian Americans. Results from 1-week and 6-month follow-up show that both OST-S and OST-CA were effective at reducing phobic symptoms compared with self-help control. Moreover, OST-CA was superior to OST-S for several outcomes. For catastrophic thinking and general fear, moderator analyses indicated that low-acculturation Asian Americans benefitted more from OST-CA than OST-S, whereas both treatments were equally effective for high-acculturation participants. Although cultural process factors (e.g., facilitating emotional control, exploiting the vertical therapist-client relationship) and working alliance were predictive of positive outcomes, they did not mediate treatment effects. This study offers a potential model for evaluating cultural adaptation effects, as well as the mechanisms that account for such effects.

Comparing the effectiveness of three substance use interventions for youth with and without homelessness experiences prior to treatment.

OBJECTIVE: Many adolescents and young adults receiving substance use treatment have experienced or are at risk for homelessness. It is unknown whether specific treatment approaches are more or less effective for youth experiencing homelessness (YEH) compared to stably housed youth. The present study compared the effectiveness of the Adolescent Community Reinforcement Approach, Motivational Enhancement Therapy combined with Cognitive-Behavioral Therapy (MET/CBT), and Treatment as Usual (TAU) for these two groups. Further subgroup differences were investigated by age, sex, and sexual and gender minority status. METHOD: YEH (n = 855) and a matched sample of stably housed youth (n = 855) were drawn from the Global Appraisal of Individual Needs, a nationwide substance use treatment data set. Multiple-group latent change score modeling was used to examine change in substance use frequency and related problems at baseline, 3-, 6-, and 12-month follow-ups. RESULTS: Results indicated significant declines in substance use frequency and problems during treatment for all intervention groups. The TAU group showed the greatest declines in substance use problems during treatment and the greatest declines in frequency post-treatment. Compared to stably housed youth, YEH entered treatment with greater substance use and problems, and had greater declines in substance use in the MET/CBT group only. Other differences were found by age and sex. CONCLUSIONS: Overall, all three substance use interventions appear to be effective in reducing substance use and related problems. TAU and MET/CBT may be particularly effective for YEH in treatment settings. Implications for future research and practice are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A critical review of current evidence on multiple types of discrimination and mental health.

Little is known about people who experience multiple types of discrimination (e.g., racism and heterosexism). While some work suggests that multiply discriminated groups are at higher risk for poor mental health, other studies propose that they may develop resilience against additional kinds of discrimination. We conducted a review of published studies on the relationship between multiple types of discrimination and mental health to critically examine evidence in support of broad risk and resilience models. Using PRISMA guidelines, we identified 40 studies that met our inclusion criteria. Typically, studies examined either whether experiencing multiple discrimination was related to poorer mental health, or whether one kind of discrimination was more predictive of poor mental health. Studies generally showed support for the risk model, with multiple forms of discrimination associated with higher risk for depression symptoms. Furthermore, both racism and heterosexism uniquely predicted symptoms of depression, although initial evidence suggested that only heterosexism predicted suicidality among lesbian, gay, bisexual, transgender, and queer (LGBTQ) racial/ethnic minorities. Findings on multiple discrimination and other mental health problems (e.g., anxiety, posttraumatic stress disorder [PTSD], distress, and substance use) were mixed. The current evidence suggests that multiply discriminated groups exhibit higher risk for some mental health problems, particularly depression symptoms. However, methodological problems abound in this literature (e.g., correspondence between study sample and types of discrimination assessed), which limits our ability to draw clear conclusions about multiple discrimination. We propose that to further our understanding of how multiple kinds of discrimination may affect mental health, studies must remedy these and other issues. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Pilot Evaluation of a Conservation Corps Program for Young Adults.

Education and employment programs may be effective at reducing problem behaviors among at-risk young adults. This pilot study evaluated whether participants in a Conservation Corps program (N = 100) showed changes in antisocial behavior, gang membership, and substance use during the program. Participants were young adults between 18 and 24 years who were predominantly male (60%) and ethnic minority (62% Latino; 31% African American). Over the course of the 22-week program, participants showed significant decreases in self-reported antisocial behavior and gang involvement, and approximately 28% earned a high school diploma. However, only 61% completed the program, and subgroup analyses suggested that decreased gang membership and antisocial behaviors were mostly driven by program completers. These limited pilot results suggest that the Conservation Corps offers vulnerable young adults opportunities for education advancement and a possible pathway to criminal desistance. However, education and employment programs should make retention a priority.

Evidence-based psychosocial treatments for ethnic minority youth.

This article reviews research on evidence-based treatments (EBTs) for ethnic minority youth using criteria from Chambless et al. (1998), Chambless et al. (1996), and Chambless and Hollon (1998). Although no well-established treatments were identified, probably efficacious or possibly efficacious treatments were found for ethnic minority youth with anxiety-related problems, attention-deficit/hyperactivity disorder, depression, conduct problems, substance use problems, trauma-related syndromes, and other clinical problems. In addition, all studies met either Nathan and Gorman's (2002) Type 1 or Type 2 methodological criteria. A brief meta-analysis showed overall treatment effects of medium magnitude (d = .44). Effects were larger when EBTs were compared to no treatment (d = .58) or psychological placebos (d = .51) versus treatment as usual (d = .22). Youth ethnicity (African American, Latino, mixed/other minority), problem type, clinical severity, diagnostic status, and culture-responsive treatment status did not moderate treatment outcome. Most studies had low statistical power and poor representation of less acculturated youth. Few tests of cultural adaptation effects have been conducted in the literature and culturally validated outcome measures are mostly lacking. Recommendations for clinical practice and future research directions are provided.

Depression in Latino adolescents: a cultural discrepancy perspective.

Latino adolescents report high levels of depression compared to other youth, yet little is known about how culture-specific factors contribute to risk (Blazer, Kessler, McGonagle, & Swartz, 1994; Roberts, Roberts, & Chen, 1997; Roberts & Sobhan, 1992; Twenge & Nolen-Hoeksema, 2002). In this study we evaluated the link between cultural discrepancy (i.e., perceived acculturation and gender role disparity between children and their parents) and depression among children of Latino immigrants. Compared to boys, Latina adolescents reported greater differences in traditional gender role beliefs between themselves and their parents and higher levels of depression. Gender role discrepancy was associated with higher youth depression, with this relationship mediated by increases in family dysfunction. Moreover, a moderator analysis suggested that gender role discrepancy effects may be most pronounced for Latina adolescents. Gender role discrepancy was associated with poorer family functioning for girls but not for boys, although the interaction effect was only marginally significant. These preliminary results point to the importance of considering cultural discrepancy as a contributing factor to youth depression.

Effects of mental health interventions with Asian Americans: A review and meta-analysis.

OBJECTIVE: Evidence demonstrating treatment efficacy for ethnic minorities has grown in recent years; however, Asian Americans (i.e., of East Asian or Southeast Asian heritage) are mostly excluded from recent reviews. In this review we (a) synthesize the literature on mental health treatment effects for Asian Americans and (b) evaluate support for competing theoretical perspectives on cultural tailoring. METHOD: A literature search supplemented with other search strategies identified 21 randomized trials of mental health interventions for Asian Americans (n = 6,377 total participants). The meta-analysis was based on random-effects models. RESULTS: Overall, results show that posttreatment effects were relatively large and significant (d = .75, SE = .14, p = .000). However, there was substantial heterogeneity across studies (ES range = -.04 to 2.61), with moderator analyses indicating that effects differed significantly by target problem, diagnostic status, and comparison group. Also, specificity of cultural tailoring was significantly associated with treatment outcomes, with treatments tailored specifically for Asian subgroups (e.g., Chinese Americans) showing the largest effects (d = 1.10), and those with no cultural tailoring or non-Asian tailoring (d = .25) showing the smallest effects. CONCLUSIONS: Findings suggest that mental health treatments are efficacious for Asian Americans and that cultural tailoring can enhance treatment outcomes. In general, these findings lend support to the cultural responsiveness hypothesis, although caveats are noted. Implications for psychotherapy research with Asian Americans are discussed, as well as methodological and conceptual challenges. (PsycINFO Database Record (c) 2018 APA, all rights reserved).