By: Oralia Gonzalez Multicultural Evidence- Based Practice

What is Evidence-Based Therapy

Evidence-Based Practice and Multiculturalism Acceptance is increasing Originally focused on research-supported therapies for specific disorders Now broadened to include clinical expertise Multiculturalism without strong research = empty political value EBT without cultural sensitivity = irrelevancy There is still resistance and distrust Research is limited but all mental health professions support that treatment should be research based.

Empirically Supported Treatment (EST) “Validated” treatments confirmed as effective for specific disorders Addressed issue of unintended harm from ineffective or hazardous treatments Specific treatment protocol for specific disorders using manuals Guidelines can be consulted and modified when working with different clients Treatment approaches should be research-based rather than idiosyncratic, personal beliefs or sketchy theories

Guidelines to Define and Identify ESTs 1. Superiority to a control in 2 or more methodologically rigorous, controlled studies 2. Equivalence to a well-established treatment in several rigorous and independent controlled studies, usually randomized controlled trials 3. Efficacy in a large series of single-case controlled designs (e.i., within-subjects designs that systematically compare the effects of a treatment with those of a controlled condition)

Identified ESTs Anxiety Depressive and stress-related disorders Obesity and eating disorders Severe mental conditions such as schizophrenia and bipolar disorders Substance abuse and dependence Childhood disorders Borderline personality disorders

Examples of Empirically Supported Treatments “Well-Established” Treatments“Probably Efficacious” Treatments Cognitive-behavioral therapy for panic disorder Cognitive therapy for obsessive- compulsive disorder (OCD) Exposure/guided mastery for specific phobias Exposure treatment for posttraumatic stress disorder (PTSD) Cognitive therapy for depressionBrief dynamic therapy for depression Cognitive-behavioral therapy for bulimiaBrief dynamic therapy for opiate dependence Cognitive-behavioral relapse prevention for cocaine dependence Interpersonal therapy for bulimia Behavior therapy for headacheReminiscence therapy for geriatrics patients Behavior marital therapyEmotionally focused couples therapy

American Psychological Association New ESTs Additions Ethnic Minorities, 1993 Women and girls, 2007 Older adults,2009 Lesbian, gay, and bisexual clients, 2012

Shortcomings of ESTs Due to focus on choosing a treatment for a specific disorder, contextual, cultural, and other environmental influences are not adequately considered. The validity for minority groups is often questionable because they are not included in clinical trials. Importance of therapist-client relationship is not adequately acknowledged. Too much emphasis is placed randomized controlled trials versus other forms of research, such as qualitative research designs. When treating clients with specific disorders, multicultural therapist have had the choice to ignoring ESTs or adapting to them.

Cultural Adaptations Matching language, racial or ethnic Incorporating cultural values in the specific treatment strategies Utilizing cultural sayings or metaphors in treatment Considering the impact of environmental variables Acculturation conflicts Discrimination Income status

Adapted ESTs Outcomes Been successful with several minority groups Latino/a and Haitian adolescents Asian Americans experiencing depression American Indians suffering from trauma African Americans recovering from substance abuse Most effective had the most cultural adaptations Most effective because therapist explore the “illness myth” of the client and the process of listening enhances outcome

Implications ESTs for ethnic minorities has been insufficiently researched Challenge to select effective interventions for each individual client Standard ESTs Adapted ESTs Develop and research a culture-specific EBT Culture-specific treatments may not be effective with a more acculturated ethnic minority Best approach is a research-based intervention and adapt it to the client’s individual characteristics, values, and preferences

Empirically Supported Relationships American Psychological Association Division29 Psychotherapy Task Force’s conclusions: Makes substantial and consistent contributions to psychotherapy outcome, independent of specific type of treatment Acts in concert with discrete interventions, clients characteristics, and clinician qualities in determining treatment effectiveness Adapting or tailoring the therapy relationship to specific client needs and characteristics enhances the effectiveness of treatment Practice and treatment guidelines should explicitly address therapist behaviors and qualities that promote a facilitative therapy relationship

Empirically Supported Relationship Variables Demonstrated EffectivePromising and Probably Effective Therapeutic AlliancePositive regard Cohesion in group therapyCongruence/genuineness EmpathyFeedback Goal consensus and collaboration Repair of alliance ruptures Customizing therapySelf-disclosure Management of countertransference

Therapeutic Alliance Three elements of Conceptualization An emotional or interpersonal bond between therapist and client Mutual agreement on appropriate goals, emphasis on changes valued by client Intervention strategies or tasks that are viewed as important and relevant by client and therapist Core conditions of effective treatment: Empathy, Respect, Genuineness, and Warmth Outcome: Clients feel understood, safe, and encouraged to disclose intimate material Sense of connectedness with therapist

Relational-Style Counselor Preferences of Ethnic Group Clients ThemesAfrican-American Clients Latino ClientsNon-Latino White Clients ListeningListen to who the client is; recognize that clients are experts on themselves. Listen in a way that communicates “paying attention.” Listen so that the client is comfortable enough to talk and express feelings UnderstandingUnderstand beyond immediate impressions; understand hidden aspects of the client. Understand feeling of clients. Understand complexity of client choices and circumstances. Counselor QualitiesCounselor should “lower” self to client’s levels; egalitarian relationship. Be authoritative, but connect first, then offer concrete advice and solutions. Not judge because of social distance; maintain professional distance but be human. Spending TimeNot listed as factor.Take time to connect deeply. Allow time for feelings to emerge at their own pace.

Emotional or Interpersonal Bond Collaborative partnership based on: Empathy Cognitive empathy – ability to understand the issues facing the client Positive regard, Genuineness, Respect, and Warmth Self-disclosure Controversial, may enhance the therapeutic relationship or interfere with the therapist-client relationship Management of Countertransference Goal Consensus

Evidence-Based Practice and Diversity Issues in Therapy Requires a comprehensive understanding of the client’s background and problem; considers best approach to provide the best outcome Accepts research evidence from qualitative studies, clinical observations, systematic case studies, and interventions derived in naturalistic settings Clinical expertise focuses on skills essential for comprehensive assessment of the client’s problems and client strengths Based on ongoing emphasis on client characteristics, culture, and preferences and the importance of working collaboratively with the client to develop goals and treatment strategies that are mutually agreeable.

Best available research Clinical expertise Patient characteristics, culture, and preferences EBP Decisions

Case Study Anna is a 14-year-old American Indian female who was sexually abused by a 22-year-old male in her small community. Anna disclosed the abuse to her school counselor, who then reported the incident to tribal law enforcement. After word of the incident spread through the community, several individuals accused Anna of lying and then harassed her in an attempt to recant her allegations. Anna began isolating herself at home and stopped attending school. Anna became increasingly depressed and demonstrated symptoms consistent with PTSD. How would you integrate EBP and multicultural sensitivity?