Evidence-Based Treatment & Pa3ent Diversity: What We Know & Why It Ma>ers

Transcription

1 Evidence-Based Treatment & Pa3ent Diversity: What We Know & Why It Ma>ers Stan Huey, Ph.D. Department of Psychology University of Southern California Advancing Mental Health Equity in California UCLA Semel Los Angeles, CA 3/30/17

2 Cultural Responsiveness Hypothesis PotenHal Problem with ConvenHonal Therapies: Developed for White, Western, English-speaking Majority of clinicians are White Not consider language, beliefs, worldview of culturally different When culture is ignored: Value conflicts & miscommunicahon Client discomfort & poor engagement Dropout & treatment failure So treatments must be culturally responsive & clinicians must be culturally competent

3 QuesHons We Asked in Grad School Are EVTs effechve with ethnic minorihes? SomeHmes maybe. But ozen not. Do White youth benefit more than minorihes from the same treatments? Of course Whites benefit more Do cultural adaptahons enhance outcomes for ethnic minorihes? Yes, definitely

4 5 QuesHons To Address Are treatments effechve with ethnic minorihes? Are treatment outcomes worse for minorihes compared to Euro-Americans? Does cultural tailoring enhance treatment outcomes for minorihes? Does culture ma_er? How to best address diversity in the treatment context?

5 Are Therapies EffecHve with Ethnic MinoriHes?

6 Meta-Analysis Primer What is Meta-Analysis? QuanHtaHve Review of Therapy Effects AcHve Treatment vs. Control Group in Randomized Trials (RCTs) Effect Size d=.20 is small effect d=.50 is medium effect d=.80 is large effect Effects adjusted for sample size

7 Treatment Outcome Meta-Analyses with Ethnic MinoriHes 1 Effect Size (d) Asian Ams Latino Youth EBTs for Minority Youth Minorities/ Conduct Probs Minorities/ Drug Probs Gillespie & Huey, 2015; Huey & Polo, 2008; Huey et al., 2014; Huey & Tilley, 2016

8 Mental Health Treatment Effects for Ethnic MinoriHes Across 140 Randomized Trials Effect Size (d) Anxiety Depression Externalizing Probs Schizophrenia Substance Use Smoking Trauma-Related Misc/Other Huey et al., 2014

9 EBTs for MinoriHes More than 50 EBTs for ethnic minorihes with diverse mental health problems Family systems therapies (e.g., FFT, BSFT, MDFT, MST) Interpersonal psychotherapy (IPT) Diverse cognihve-behavioral treatments (CBTs) Infant-parent relahonship therapy, mohvahonal interviewing, play therapy, and other therapies Modality doesn t seem to ma_er much Family vs. group vs. individual (e.g., Bernal; Nayamathi; Szapocznik)

10 Are Treatment Outcomes Worse for Ethnic MinoriHes vs. Euro-Americans?

11 DifferenHal EffecHveness? Reviews by Huey & Polo (2008) & Miller et al. (2007) Most relevant studies show no ethnic differences in treatment effects 15%-23% show effects favoring minoriees Results from 29 Meta-Analyses (Huey & Smith, 2014) 62% show no ethnicity effects 14% show effects that favor whites 17% show effects that favor minoriees Summary: No consistent ethnicity effects

12 Does Cultural Tailoring Enhance Outcomes for Ethnic MinoriHes?

13 General Reasons to Consider Culture Implicit bias against outgroups is the norm, & such biases affect judgment & behavior Interracial interachons can be cognihvely taxing Majority & minority groups ozen have different percephons of opportunity & discriminahon Banaji & Greenwald, 2013; Norton & Sommers, 2011; Richeson & Shelton, 2007

14 Clinical Reasons to Consider Culture SHgma Help-Seeking UnderuHlizaHon PaHent preferences Clinician/system biases Greater psychopathology or severity Symptom profile/presentahon Unique MH correlates for minorihes & immigrants A_riHon/dropout Treatment barriers

15 What is Culturally-Responsive Tx? No uniform view Many opinions, many frameworks, many labels: Culturally-competent, minority-specific, ethnicallysensihve, culturally-tailored, culturally compahble, etc. CRT = Efforts to make treatments more appropriate for ethnic minorihes

16 What is Culturally Responsive Tx? Some Pan-Minority RecommendaHons: Short-term, Hme-limited, pragmahc, direchve, goaloriented, problem-focused treatment A_enHve to effects of minority status or discriminahon Assess whether behavior matches values & norms of host culture (i.e., is it adaphve in client s culture) Assess & validate client experiences w/racism A_end to nonverbal/indirect forms of communicahon Role induchon

17 What is Culturally Responsive Tx? RecommendaHons for African Americans: Incorporate spirituality & faith-based coping Selected use of AAVE RecommendaHons for Asians/Asian-Americans: Accept & tolerate low levels of expressivity Avoid comments construed as crihcal or disapproving RecommendaHons for LaHnos: Involve family in treatment Use polite form of you (usted) with adults

18 Evidence Most minority-focused treatments are culturallytailored E.g., Huey & Polo (2008), Gillespie & Huey (2015) 10 meta-analyses summarized by Huey et al. (2014) All show that culturally tailored treatment be_er than no treatment, placebo, & services-as-usual controls BUT, do culturally tailored treatments work be_er than generic treatments? Huey (2013) meta-analysis Rigorous, direct comparison of tailored vs. generic treatments Overall effect size of d=.01, no effect

19 Effect Sizes for 10 Randomized Trials of Culturally Tailored vs. Generic Treatments Effect Size (d) Studies showing posieve tailoring effects Average Effect Size Across All Studies Studies showing negaeve tailoring effects Huey, 2013 Note: A posihve effect size means that outcomes favor the culturally tailored condihon; a negahve effect size means that results favor the generic condihon.

20 Why Might Tailoring Diminish Effects? ReacHvity Some cultural content may evoke negahve emohonal rxns Chang; Webb Less AcHvaHon of Change Mechanisms Some tailoring may distract from core strategies or create inefficiencies that interfere with achve ingredients Castro; Lau; Kumpfer et al.; Kliewer et al.

21 Kliewer, Lepore Et Al. (2011) Sample & Design Black youth (91%) in high-violence, urban neighborhoods Randomly assigned to Standard vs. Enhanced Expressive WriHng Standard Expressive WriHng Write about their deepest thoughts and feelings related to violence Culturally Enhanced Expressive WriHng Given ophon to write stories, skits, songs, or poetry about violence, and to share their work with others in the classroom RaHonale? Strong oral tradihon within African American culture Popularity of Spoken Word & role of rap in popular culture Reflects cultural experience of African Americans Results Enhanced less effeceve at reducing teacher-rated aggression! Why? Maybe less emohonal processing in enhanced condihon

22 Summary What we know so far Therapies are generally effechve for ethnic minorihes In lab and real-world setngs Many EBTs for Blacks & LaHnos And increasing for Asians Americans, indigenous populahons, & ethnic minorihes in other countries Mostly CBTs, but not exclusively MinoriHes & Euro-Ams mostly benefit equally No persuasive evidence that cultural tailoring necessarily enhances treatment effects

23 Other Diversity Categories Class Sexual OrientaHon/ID Religion Gender Immigrant status Age Region of country Disability Family structure Etc.

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25 Race & Culture Ma_er Cultural adaptahon with Asian Americans Culturally adapted OST works be_er with Asian Americans DirecHveness helps reduce depressive symptoms in Asian Americans Ethnicity moderates intervenhon effects Dissonance treatment reduces ED risk for Asian Americans but not Euro-Americans Ethnicity and treatment process Black & White families show different pa_erns of resistance over the course of treatment, with different consequences Chithambo & Huey, 2017; Huey & Pan, 2006; Pan & Huey, 2017; Pan et al., 2011; Sayegh et al., 2016

26 Addressing Diversity in Evidence- Based PracHce

27 Strategies for Addressing Diversity Strategies that allow one to consider a variety of diversity concerns while minimizing stereotyping Many consistent with manualized approaches & common sense clinical prachce Mostly derived from review of hundreds of EBPs But many don t have gold standard evidence

28 Strategies for Addressing Diversity Inclusivity Reduce access barriers Role induc3on Start & shck with client goals Fit analysis Strength-focus Cultural knowledge but avoid assumphons Humility

29 Inclusivity Diversity Cues Claude Steele & Whistling Vivaldi Diverse staff, pictures, brochures, etc. U Wisconsin brochure Wood website Use sensihve and inclusive language Use partner vs. boyfriend Donald Trump Bernie Sanders

30 Role InducHon Key elements of role induchon Review expected frequency of a_endance & services available Elicit treatment expectahons & correct mispercephons Clarify therapist & client responsibilihes Elicit reasons for entering treatment & discuss how treatment relates to idenhfied problems Elicit barriers to a_endance & problem-solve Improves engagement & reduces dropout for ethnic minority clients (Katz et al., 2004)

31 Humility

32 Humility We ozen don t know what we don t know We have self-serving & self-enhancing biases Therapists give inflated rahngs of competence/adherence Generally, experienced therapists no be_er than novices Solicit client s perspechve & experiences, but Don t presume you ll truly understand that experience, esp. if cultural differences Southpark

33 Contact: Stan Huey, Ph.D. Phone: University of Southern California Department of Psychology, SGM S. McClintock Ave. Los Angeles, CA References: Huey, S. J., Jr., & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic minority youth. Journal of Clinical Child and Adolescent Psychology, 37, Huey, S. J., Jr., Tilley, J. L., Jones, E. O., & Smith, C. (2014). The contribuhon of cultural competence to evidence-based care for ethnically diverse populahons. Annual Review of Clinical Psychology, 10, Huey, S. J., Jr., & Wood, L. (Winter, 2014). A marriage of research and prachce: AdapHng evidence based prachces for diverse populahons. The California Psychologist, 8-9. Sayegh, C.A., Hall-Clark, B.N., McDaniel, D.D., et al. (2016). A preliminary inveshgahon of ethnic differences in resistance in MulHsystemic Therapy. Journal of Clinical Child and Adolescent Psychology.

34 Hyperlinks

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36 Bias as Zero-Sum Game

37 What NOT to do

38 What NOT to do