What is cultural competence in research?

Cultural competence — loosely defined as the ability to understand, appreciate and interact with people from cultures or belief systems different from one's own — has been a key aspect of psychological thinking and practice for some 50 years. It's become such an integral part of the field that it's listed as one of psychology's core competencies. The federal government, too, views it as an important means of helping to eliminate racial, ethnic and socioeconomic disparities in health and mental health care.

But defining, understanding and applying cultural competence in treatment hasn't been easy. For one thing, researchers are still arguing over the basic ingredients of cultural competence and culturally competent care. What makes a particular therapist, practice, or protocol, culturally competent? While there is plenty of speculation on the topic, answers to these questions are a long way from being settled.

What's more, funding for this kind of research has generally been scant (see "Institute focuses on patients, including their ethnicity"). The National Institutes of Health tends to require a biomedical aspect in most mental health research, including that involving cultural competence. And the one NIH institute dedicated to ethnic-minority health issues, the National Institute of Minority Health and Health Disparities, is one of the lowest funded NIH agencies and tends to put more money into training than research, field leaders say.

In addition, the area has been fraught with disagreement and controversy. Some researchers think interventions should be more radical than they are, while critics assert such interventions are merely another form of "political correctness."

As a result of these complexities, the science of culturally competent treatment has tended to receive short shrift, many say. But thanks to a range of research efforts, that has been changing, according to an expert in the area, Utah State University psychology professor Melanie Domenech Rodriguez, PhD.

"Psychologists of my generation, in collaboration with those of previous generations, are working to put the science more squarely into cultural competence and culturally competent treatment," she says.

Cultural adaptations

This thrust to improve the scientific aspect of culturally competent treatment research means that a central research focus has been a pragmatic one: modifying evidence-based treatments for different groups, otherwise known as "cultural adaptations." The tack follows a long period of treatment and research experimentation beginning in the 1960s that included, among other approaches, involving community members integrally in treatment design and intervention.

While cultural adaptation research doesn't take such a complete grassroots approach, it has the distinct advantage of appealing more to funders. Because it starts with a scientifically validated treatment and adds components to or tweaks it, this kind of research is easier to manage from a research perspective than, say, creating a treatment from scratch.

"If the wheel works relatively well, I'd like to use it," says University of Puerto Rico psychologist Guillermo Bernal, PhD, who with Domenech Rodriguez co-edited the 2012 APA book "Cultural Adaptations: Tools for Evidence-Based Practice with Diverse Populations."

Bernal helped to launch this kind of research in the 1990s when he realized he was informally adapting evidence-based treatments to his clients anyway.

"We very consciously began looking at the protocols of those treatments and deconstructing them in terms of cultural metaphors and assumptions and language," he says.

In the first study utilizing this framework, University of Puerto Rico psychologist Jeannette Rosello, PhD, and Bernal compared how Puerto Rican teenagers with depression responded to culturally adapted versions of cognitive behavioral therapy (CBT) and interpersonal therapy (IPT), compared with peers on a wait list. Both adapted treatments were effective and both were superior to control group outcomes, they found (Journal of Consulting and Clinical Psychology, 1999).

In a 2008 study published in Cultural Diversity and Ethnic Minority Psychology, Rosello, Bernal and Carmen Rivera-Medina, PhD, compared adapted group and individual versions of cognitive behavioral therapy and interpersonal theory, again with depressed Puerto Rican teens. All were effective, but both group and individual CBT worked faster than either form of IPT, the team found. (These adaptations are all now part of the Substance Abuse and Mental Health Service Administration's Registry of Evidence-Based Therapies, available to the public.)

Other studies have shown similar successes. In a 2014 issue of the Journal of Latina/o Psychology, Marquette University psychology professor Robert A. Fox, PhD, and colleagues looked at the effects of providing a culturally adapted version of their evidence-based parenting intervention Early Pathways to at-risk Latino children. The kids improved significantly on behavioral and emotional measures compared with those on a waiting list, the team found.

Meanwhile, University of California, Los Angeles, associate professor Anna Lau, PhD, and colleagues successfully adapted an evidence-based intervention called The Incredible Years to Chinese-American parents. The adaptation incorporated earlier findings about the kinds of situations most likely to spur punitive parenting practices among Chinese-American parents, such as distress over their children's academic performance or expressed desire for more autonomy. The researchers found the adaptation fostered more positive and fewer negative parenting practices and reduced kids' acting out and depression (Journal of Clinical Psychology, 2010).

How do they look overall?

In general, meta-analyses confirm the effectiveness of such adaptations.

One, reported by Timothy B. Smith, PhD, Domenech Rodriguez and Bernal in a 2011 article in the Journal of Clinical Psychology, looked at 65 experimental and quasi-experimental studies that included some form of adapted treatment. Adaptations for ethnic-minority clients were moderately more effective than treatment as usual with the same clients, and treatments with many versus few cultural adaptations were particularly effective, they found. In addition, services targeted to one specific group, say, Bhutanese immigrants, were several times more effective than treatments provided to clients from a variety of cultural backgrounds.

Another meta-analysis, reported in the Journal of Counseling Psychology by University of Wisconsin–Madison psychologists Steven G. Benish, PhD, Stephen Quintana, PhD, and Bruce E. Wampold, PhD, analyzed 21 studies comparing psychotherapy interventions that were either culturally adapted or not. The adapted versions had better outcomes, they found.

The team also examined factors that might explain the effectiveness of the evidence-based adapted therapies. Only treatments that explicitly addressed a client's own cultural views of his or her illness had better outcomes than non-adapted treatments. Other variables — such as treatment modality, the ethnic match of therapist and client, and the severity of the disorder — made little difference.

A third meta-analysis reported in the Annual Review of Clinical Psychology in 2014 reached a more reserved conclusion. In a summary of 10 recent meta-analyses — including those of Smith and Benish — Stanley J. Huey Jr., PhD, of the University of Southern California, and colleagues, found that non-adapted psychotherapy was generally effective with ethnic-minority clients — a finding that in part counters criticisms that individual Western-style therapy may not be the best choice for many ethnic-minority people.

That finding held up across cultural groups and mental health problems. Less clear, though, was whether adding culturally tailored strategies provided extra value. Sometimes these additions had a positive effect, but other times their effects were neutral or negative.

A work in progress

Mixed findings like these underscore the fact that the field still has plenty of room to grow. To this end, researchers are exploring areas they think are important to help advance science and practice in cultural competence, both related and unrelated to cultural adaptations.

For example, researchers are developing frameworks to guide the adaptation of evidence-based treatments. Wei-Chin Hwang, PhD, a clinical psychologist at Claremont McKenna College, lays out principles for doing this in ways intended to help researchers create good study designs and best incorporate community input — known as "top down" and "bottom up" approaches, respectively.

In a 2006 article in the American Psychologist, Hwang calls for researchers and practitioners to understand differing cultural beliefs about mental illness and how people of different cultures express and communicate distress, while a 2009 article in Professional Psychology: Research and Practice provides five steps to help researchers collaborate with community partners to generate and support ideas for therapy adaptation. Hwang then describes ways to integrate the two approaches in a chapter in the APA book "Cultural Adaptations." Bernal, too, has developed an adaptation model that examines the roles of language, cultural metaphor and acceptability of treatment to those the adaptation is serving.

Others are adding to or modifying their work with cultural adaptations based on experiences in the field. Lau is taking insights gleaned in her original study — namely, therapists' own ideas on which types of adaptations might best suit different families — and investigating whether and how those insights might help sustain evidence-based interventions for youth. In a study called 4KEEPS, she and psychologist Lauren Brookman-Frazee, PhD, of the University of California, San Diego, are using a grant from the National Institute of Mental Health to assess how more than 1,500 therapists in Los Angeles county are implementing evidence-based treatments up to eight years after initial adoption. Do they stay faithful to the original protocol? More important, says Lau, what are therapists doing on their own to ensure these treatments work in community settings, and can those findings be incorporated into future treatments?

Alfiee Breland-Noble, PhD, who directs the African-American Knowledge Optimized for Mindfully-Healthy Adolescents, or AAKOMA, Project at Georgetown University, brings her existing knowledge of African-American culture into treatments she perceives are already a good fit for this population. For instance, research shows that, for historical reasons, African-Americans can be highly resistant to mental health treatment. That's why Breland-Noble starts with treatments that are more attractive to this group, such as motivational interviewing, with its emphasis on client empowerment. Instead of tailoring the treatment, she includes practices that foster clients' willingness to take part in it.

"My intervention is really designed for treatment engagement, to increase people's willingness to access treatments, including culturally adapted treatments," she says.

Researchers also are working to incorporate a more individualized understanding of families and culture into culturally competent intervention research and practice. Among them is Steven Lopez, PhD, a cross-cultural psychology researcher at the University of Southern California. He and colleagues including Stanley Sue, PhD, distinguished professor of clinical psychology at Palo Alto University, and others, emphasize the importance of understanding specific factors that inform an individual's or family's presenting problems — not simply the research wisdom about their ethnic group as a whole.

To give a nuanced example, studies of Mexican-Americans with serious mental illness suggest these clients tend to relapse when they return to family members who are inclined toward emotional over-involvement. Studies of European-Americans show they fare worse when they return to homes high in criticism.

But it would be a mistake to assume that emotional overinvolvement is always a relapse trigger for Mexican-American clients, or that high levels of family criticism always predict relapse in European-American clients, says Lopez. Instead, it's important to assess individual families and see what the likely predictors might be for that particular family.

"We are not saying we need a cultural adaptation for Mexican-Americans that includes emotional over-involvement," he says. "It's too static, too set, too stereotyping and it's not considering the individual."

Also at issue is whether it's desirable or even possible to gain specific cultural competence in more than one or two cultures. For instance, although Domenech Rodriguez has spent 18 years collaborating on interventions with partners in Mexico, she continues to learn important lessons about that country's enormous cultural diversity.

"I can't imagine trying to develop the nuances of knowledge I have had to acquire in Mexico with every group imaginable," she says.

Finally, the still-murky definition of cultural competence continues to stymie efforts to properly design studies in the area. To this end, Domenech Rodriguez favors the idea of observing master practitioners and seeing what they have in common. "We really need to do some observational work with people we agree are exquisitely culturally competent," she says.

In a related vein, Sue, Huey and others suggest the approach of first looking at study outcomes, then seeing which factors distinguish those that are particularly effective with ethnic-minority clients.

"We obviously have the usual kinds of recommendations — we need more randomized controlled trials," says Sue. "But I think we should try to get some insights in different ways, such as using specific qualitative strategies."

In some ways, it's a plus that the field is still in a major mode of questioning, Sue adds.

"It means people will keep on studying and analyzing cultural competence and culturally competent interventions," he says.

The result, he believes, will be more helpful and empirically grounded interventions.

Tori DeAngelis is a journalist in Syracuse, New York.

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