1

Culturally relevant EBP

Running head: CULTURALLY RELEVANT EBP

Culturally Relevant Evidence-Based Practice (EBP): The Future of Psychology.

Amina Mahmood

October 2nd, 2006

*Completed in fulfillment of the Counseling Psychology Portfolio Requirement

The University of Iowa

Abstract

This position paper advocates for incorporating cultural relevance in the practice of evidence-based practices (EBPs) in psychology. EBPs are defined and a brief historical overview of the movement is provided. Empirically supported treatments (ESTs) are considered under the umbrella of EBPs. The author argues that responsible practice of psychology requires the development of culturally relevant EBPs. Psychotherapy research with culturally diverse populations is needed in order to develop culturally relevant practices in psychology. Reasons for advocating for the culturally relevant practice of psychology are discussed, and challenges to the development of culturally relevant practices are also addressed.

Culturally Relevant Evidence-Based Practice (EBP): The Future of Psychology.

Introduction

The rise of evidence-based practice (EBP) movement is shaping the practice of psychology today.Additionally the past two decades have also seen the rise of managed care and Health Maintenance Organizations (HMOs), which have influenced the practice of psychology. HMOs, insurance companies, and other health care funding agencies are beginning to restrict reimbursement of psychological services, by only reimbursing practitioners for empirically supported treatments (ESTs) (Norcross, Beutler, & Levant 2006).

The EBP movement has caused considerable debate among psychologists. Some psychologists have embraced the EBP movement, whereas others have opposed it. There are also some who are approaching EBP movement cautiously and are critiquing and making recommendations to modify the definition of EBPs in psychology. In this paper EBPs are defined, and a brief historical overview of the EBP movement is provided. I will then present arguments underscoring the importance for developing culturally relevant EBPs in psychology. Finally, challenges to the development of culturally relevant EBPs will be outlined.

Defining EBPs

In order to define EBPs it is important to consider the historical context of the EBP movement. The EBP movement is one of two contemporary evidence-based movements and originated in the United Kingdom. EBP is based on medical practice with importance is placed upon optimizing treatment outcomes by using research evidence to inform practice (Wampold & Bhati, 2004). The American counterpart of EBP is the EST movement. The EST movement gained momentum in 1993 with the establishment of a task force for the promotion and dissemination of empirically validated treatments in APA’s Division 12 (Clinical Psychology); this task force is now a standing committee within Division 12 (Wampold & Bhati, 2004). The EST movement places importance on identifying specific treatments that are efficacious for specific disorders (Chambless, Sanderson, Shoham, Bennett Johnson, Pope, Crits-Cristoph, et al., 1996). Both the EBP and EST movements are based on the medical model. The EBP movement values the meta-analytic technique to identify EBPs, and the EST movement places emphasis on randomized controlled trials (RCTs) (Wampold & Bhati, 2004; Norcross et al., 2006). Large-scale clinical trials that are conducted by the Food and Drug Administration (FDA) have provided both the EBP and EST movements with a model for determining the effectiveness and efficacy of psychological treatments (Wampold & Bhati, 2004).

The American Psychological Association (APA) has recently published a definition of EBPs which states that EBPs in psychology are “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 273, APA Presidential Task Force on Evidence-Based Practice, 2006). Distinctions between EBPs and ESTs are also identified. ESTs are viewed as a component of EBPs. The EST movement is concerned with specific treatments whereas the EBP movement encompasses a broader range of empirically supported practices to enable psychologists in achieving optimal clinical outcomes (APA Presidential Task Force on Evidence-Based Practice, 2006; Goodheart & Kazdin, 2006). Proponents of the EBP movement maintain that EBPs are a broader concept than ESTs. However EBPs continue to underscore psychological treatments and tend to ignore other aspects of psychological practice that are related to positive treatment outcomes (Wampold & Bhati, 2004), for instance common factors (including, therapeutic alliance, trust, empathy) which account for a considerable amount of variance in treatment outcomes (Lambert & Ogles, 2004). For the purposes of this paper ESTs will be considered under the umbrella of EBPs.

The definition of EBPs in psychology cautions practitioners to consider the context and culture of the client/patient when determining which evidence-based practice to utilize. However, it should be noted that there is a scarcity of research literature examining the cultural relevance of EBPs in psychology.

The need for culturally relevant EBPs

Culture plays a critical role in the assessment, etiology, symptom expression, and treatment of psychological illness. By 2050 approximately half of the American population will be comprised of ethnic minorities (U.S. Census Bureau, 2001). Research literature in psychology and reports from governmental organizations point to the continued underutilization of psychological services by ethnic minorities along with the increasing need and demand for such services (Bernal & Scharron-del-Rio, 2001; LaRoche & Turner, 2002; Nagayama Hall, 2001; U.S. Surgeon General, 2001). If the need and demand for psychological services is increasing among ethnic minority and other culturally diverse groups why do disparities in utilization continue to exist?

A few reasons for why EBPs have not been helpful in reducing treatment disparities for ethnic minorities, these include: the scarcity of research with ethnic minorities, limited definition of “evidence,” and the limited research on the effectiveness of current evidence-based interventions for ethnic minorities (LaRoche & Turner, 2002; Miranda, Nakamura, & Bernal, (2003); Nagayama Hall, 2001).

One argument for the disparity between demand and utilization psychological services for ethnic minority and other culturally groups stated above is the absence of research on culturally relevant practices in psychology (U.S. Surgeon General, 2001). This lack of research means that we do not know if ESTs are effective for ethnic minorities (Nagayama Hall, 2001). RCTs conducted to establish efficacy of ESTs have primarily been conducted with Western White participants and culture as a variable has been overlooked in this research (Miranda, Nakamura, & Bernal, 2003).

Another challenge for developing culturally relevant EBPs pertains to the limited definition of “evidence.” The methodology used to determine the efficacy and effectiveness of EBPs lends itself favorably to certain treatments, and this is evident on EST lists in which cognitive behavioral treatments (CBT) are well represented. In order to establish evidence-based practices for culturally diverse populations researchers should consider using methodology that is not biased towards certain types of treatments.

Although the research on the effectiveness of EBPs with ethnic minority and culturally diverse populations is limited at best, practitioners continue to use EBPs with these populations. Generalizing EBPs for populations for whom effectiveness evidence does not exist is questionable. Although the use of EBPs with ethnic minority groups is being advocated despite minimal or no effectiveness evidence would we advocate for the use of EBPs developed with ethnic minority groups to be used with the general population (Bernal &Scharron-del-Rio (2001)?

It is also important to remember that psychotherapy is a culture-laden practice, and has been based on the cultural values of the Western White middle class population (Sternberg, 2006). Psychological treatments will have positive outcomes if the cultural backgrounds of the client/patient are reflected in the theoretical base and in the strategies of interventions used (LaRoche & Turner, 2002). Culturally relevant EBPs can be developed if researchers begin to explore the concepts and meaning of psychological health and well being for specific cultural groups.

Conclusion and Limitations

Literature indicates that culturally sensitive psychological interventions contribute to an increase in client’s satisfaction with psychotherapy, the length of treatment, utilizing psychological services, and positive therapy outcomes (Atkinson, Bui, & Mori, 2001). Therefore, efforts need to be directed towards the development and establishment of culturally relevant EBPs.

Challenges to the development of culturally relevant EBPs have been discussed at length by Coleman & Wampold (2003). These challenges include the limitations posed by current standard research methodology used to establish the effectiveness and efficacy of treatments, the absence of theory pertaining to culturally relevant treatments, lack of information to determine defining features of specific cultural populations, difficulties in establishing culturally relevant definition of psychological change, and lack of measures that have been normed for culturally diverse populations (p. 228).

Locating funding resources and obtaining funding to conduct research focused on the development of culturally relevant EBPs also poses a challenge for researchers. Challenges are also associated with recruiting ethnic minority and culturally diverse individuals to participate in the research process, and this is an impediment to the research process. However, it is important to recognize that practitioners are working with culturally diverse clients daily, and are continually incorporating culturally relevant practices into their practice to meet the needs of their client. Practitioners then, are a valuable resource of information, and a potential starting point for research and development of culturally relevant practices. The current EBP movement will benefit from practice that informs science, rather than placing emphasis solely on science informing practice (Weisz & Addis, 2006).

In conclusion, there are many challenges that need to be addressed in the development of culturally relevant EBPs. The stronghold of HMOs and managed care companies over the practice of psychology is tremendous, and practitioners are being pushed towards providing EBPs. However, in order to practice responsibly with the culturally diverse populations that we will inevitably encounter and in order to meet HMO and managed care criteria for treatment reimbursement it becomes imperative that we advocate for the development of culturally relevant EBPs.

References

APA Presidential Taskforce on Evidence-Based Practice (2006). Evidence-based practice

in psychology. American Psychologist, 61, 271-285.

Atkinson, D. R., Bui, U., & Mori, S. (2001). Multiculturally sensitive empirically

supported treatments—an oxymoron? In J. G. Ponterotto, J. Manuel Casas, L. A. Suzuki, & C. M. Alexander (Eds.). Handbook of Multicultural Counseling (2nd ed., p. 542-574).

Bernal, G. & Scharron-del-Rio, M. R. (2001). Are empirically supported treatments valid

for ethnic minorities? Toward an alternative approach for treatment research. Cultural Diversity and Ethnic Minority Psychology, 7, 328-342.

Chambless, D. L., Sanderson, W. C., Shoham, V., Bennett Johnson, S., Pope, K.S., Crits-

Cristoph, P., et al. (1996). An update on empirically validated therapies. The Clinical Psychologist, 49, 5-18.

Coleman, H. L. K. & Wampold, B. E. (2003). Challenges to the development of

culturally relevant, empirically supported treatment. In D. B. Pope-Davis, Coleman, H. L. K., Liu, W. M., & Toporek, R. L. (Eds.). Handbook of Multicultural Competencies in Counseling and Psychology (p. 227-246).

Goodheart, C. D. & Kazdin, A. E. (2006). Introduction. In C. D. Goodheart, A. E.

Kazdin, & R. J. Sternberg (Eds.). Evidence-Based Psychotherapy: Where Practice and Research Meet. (p. 3-10).

Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy.

In M. J. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (5th ed., p. 139-193). New York: John Wiley & Sons, Inc.

LaRoche, M. J. & Turner, C. (2001). At the crossroads: managed mental health care, the

ethics code, and ethnic minorities. Cultural Diversity and Ethnic Minority Psychology, 8, 187-198.

Miranda, J., Nakamura, R., & Bernal, G. (2003). Including ethnic minorities in mental

health intervention research: a practical approach to a long-standing problem. Culture, Medicine, and Psychiatry, 27, 467-486.

Nagayama Hall, G. C. (2001). Psychotherapy research with ethnic minorities: empirical,

ethical, and conceptual issues. Journal of Consulting and Clinical Psychology, 69, 502-510.

Norcross, J. C., Beutler, L. E., & Levant, R. F. (2006). Prologue. In J. C. Norcross, L. E.

Beutler, & R. F. Levant (Eds.). Evidence-Based Practices in Mental Health: Debate and Dialogue on the Fundamental Questions (p.3-12).

Sternberg, R. J. (2006). Evidence-based practice: gold standard, gold plated, or fool’s

gold? In C. D. Goodheart, A. E. Kazdin, & R. J. Sternberg (Eds.). Evidence-Based Psychotherapy: Where Practice and Research Meet. (p. 261-271).

U.S. Census Bureau (2001, January 13, 2000). Projections of the total resident

population by 5-year age groups, race and Hispanic origin with special age categories: Middle series, 2050 to 2070. U.S. Census Bureau, Population Division, Statistical Information Staff. Retrieved, September 4, 2006 from

U.S. Surgeon General (2001). Mental Health: Culture, Race, and Ethnicity—A

Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General.

Wampold, B. E. & Bhati, K. S. (2004). Attending to the omissions: a historical

examination of evidence-based practice movements. Professional Psychology: Research and Practice, 35, 563-570.

Weisz, J. R. & Addis, M. E. (2006). The research-practice tango and other choreographic

challenges: using and testing evidence-based psychotherapies in clinical care settings. In C. D. Goodheart, A. E. Kazdin, & R. J. Sternberg (Eds.). Evidence-Based Psychotherapy: Where Practice and Research Meet. (p. 179-206).