Guillermo Bernal

Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics

This article has two objectives. The first is to provide a culturally sensitive perspective to treatment outcome research as a resource to augment the ecological validity of treatment research. The relationships between external validity, ecological validity, and culturally sensitive research are reviewed. The second objective is to present a preliminary framework for culturally sensitive interventions that strengthen ecological validity for treatment outcome research. The framework, consisting of eight dimensions of treatment interventions (language, persons, metaphors, content, concepts, goals, methods, and context) can serve as a guide for developing culturally sensitive treatments and adapting existing psychosocial treatments to specific ethnic minority groups. Examples of culturally sensitive elements for each dimension of the intervention are offered. Although the focus of the article is on Hispanic populations, the framework may be valuable to other ethnic and minority groups.

Are Empirically Supported Treatments Valid for Ethnic Minorities? Toward An Alternative Approach for Treatment Research

The psychological community has given considerable attention to the problem of establishing empirically supported treatments (ESTs). The authors argue that a scientific practice that discriminates against some approaches to knowledge undermines the ESTs relevance for communities of color. They examine the EST projects contribution to knowledge of effective treatments for ethnic minorities by considering both how knowledge is constructed and the limits of research (e.g., external validity). Alternatives on how to best contribute to treatment research of clinical utility with diverse populations are articulated. An approach for treatment research, derived from an integration of the hypothesis-testing and discovery-oriented research approaches, is presented, and recommendations to advance treatment research with ethnic minority communities are offered.

Psychosocial intervention development for the prevention and treatment of depression: promoting innovation and increasing access.

Great strides have been made in developing psychosocial interventions for the treatment of depression and bipolar disorder over the last three decades, but more remains to be done. The National Institute of Mental Health Psychosocial Intervention Development Workgroup recommends three priorities for future innovation: 1) development of new and more effective interventions that address both symptom change and functional capacity, 2) development of interventions that prevent onset and recurrence of clinical episodes in at-risk populations, and 3) development of user-friendly interventions and nontraditional delivery methods to increase access to evidence-based interventions. In each of these areas, the Workgroup recommends systematic study of the mediating mechanisms that drive the process of change and the moderators that influence their effects. This information will highlight the elements of psychosocial interventions that most contribute to the prevention and treatment of mood disorders across diagnostic groups, populations served, and community settings. The process of developing innovative interventions should have as its goal a mental health service delivery system that prevents the onset and recurrence of the mood disorders, furnishes increasingly effective treatment for those who seek it, and provides access to evidence-based psychosocial interventions via all feasible means.

Prevention of depression with primary care patients: A randomized controlled trial

The prevention of major depression is an important research goal which deserves increased attention. Depressive symptoms and disorders are particularly common in primary care patients and have a negative impact on functioning and well-being comparable with other major chronic medical conditions. The San Francisco Depression Prevention Research project conducted a randomized, controlled, prevention trial to demonstrate the feasibility of implementing such research in a public sector setting serving low-income, predominantly minority individuals: 150 primary care patients free from depression or other major mental disorders were randomized to an experimental cognitive-behavioral intervention or to a control condition. The experimental intervention group reported a significantly greater reduction in depressive levels. Decline in depressive levels was significantly mediated by decline in the frequency of negative conditions. Group differences in the number of new episodes (incidence) of major depression did not reach significance during the 1-year trial. We conclude that depression prevention trials in public sector primary care settings are feasbile, and that depressive symptoms can be reduced even in low-income, minority populations. To conduct randomized prevention trials that can test effects on incidence with sufficient statistical power, subgroups at greater imminent risk have to be identified.

INCLUDING ETHNIC MINORITIES IN MENTAL HEALTH INTERVENTION RESEARCH: A PRACTICAL APPROACH TO A LONG-STANDING PROBLEM

This paper examines a controversy that arose while developing a supplement to Mental Health: A Report of the Surgeon General that was focused on ethnic minority mental health. The controversy involved whether and how to make recommendations about ethnic minorities seeking mental health care. We found that few studies provided information on outcomes of mental health care for ethnic minorities. In this paper, we discuss outcomes of mental health care for ethnic minorities and how to proceed in developing an evidence base for understanding mental health care and minorities. We conclude that entering representative (based on population) numbers of ethnic minorities in efficacy trials is unlikely to produce useful information on outcomes of care because the numbers will be too small to produce reliable findings. We also conclude that while conducting randomized efficacy trials for all mental health interventions for each ethnic group would be impractical, innovative and theoretically informed studies that focus on specific cultural groups are needed to advance the knowledge base. We call for theory-driven research focused on mental health disparities that has the potential for understanding disparities and improving outcomes for ethnic minority populations.

Culturally Adapting an Evidence-Based Parenting Intervention for Latino Immigrants: The Need to Integrate Fidelity and Cultural Relevance

Latinos constitute the largest ethnic minority group in the United States. However, the cultural adaptation and dissemination of evidence-based parenting interventions among Latino populations continues to be scarce despite extensive research that demonstrates the long-term positive effects of these interventions. The purpose of this article is threefold: (1) justify the importance of cultural adaptation research as a key strategy to disseminate efficacious interventions among Latinos, (2) describe the initial steps of a program of prevention research with Latino immigrants aimed at culturally adapting an evidence-based intervention informed by parent management training principles, and (3) discuss implications for advancing cultural adaptation prevention practice and research, based on the initial feasibility and cultural acceptability findings of the current investigation.

Latinos and latinas in community psychology: A review of the literature

Latinos and Latinas are one of the largest minority groups in the United States yet they remain a silent group. The article begins by considering the social, historical, and economic backgrounds of Latino and Latina groups in the U.S. as a context for understanding diversity and as a resource for explaining the participation of this minority group in community psychology. This article then examines the extent to which Latinos and Latinas are present and participate in community psychology throughout its publications and explores the nature of their participation through a thematic analysis of the published literature. A content analysis was conducted on 1,851 articles published from 1973 through 1992 in theAmerican Journal of Community Psychology and theJournal of Community Psychology to evaluate the presence of Latinos and Latinas in the community psychology literature. The quantitative analysis revealed that 3.7% (n=69) of all the articles reviewed focused on Latinos and Latinas or had samples with at least 15% of the participants coming from this ethnic group. Mexican Americans/Chicanos were the focus of the largest number of articles about specific Latino and Latina subgroups, followed by Cubans and Puerto Ricans. The results indicated less attention to Latino and Latina populations in the community psychology literature than would be expected from the fields goals. However, a qualitative review of the articles was more encouraging since many articles by and about Latinos and Latinas reflected values consonant with the field such as cultural pluralism or employed conceptual tools of the discipline such as empowerment or ecological approaches. Nevertheless, some of the articles reviewed also lacked a concern for the fields values in relation to Latinos and Latinas as a group. Finally, suggestions and strategies to empower this group are offered.

Suicide Behavior among Latino and Latina Adolescents: Conceptual and Methodological Issues.

Suicide is the cause of 11.7 % of all deaths among youth and young adults aged 10 to 24 years in the United States (J. A. Grunbaum et al., 2004). Suicide is third leading cause of death for young Latinos/as aged 10 to 24 years (National Institute of Mental Health, 2001). Latino/a youth are at a greater risk of suicide behavior than other ethnic groups (G. Canino & R. E. Roberts, 2001). Latinos/as have less access to mental health services than do Whites and are less likely to receive needed care (U.S. Department of Health and Human Services, 2001). This article reviews the scientific literature related to suicide behavior among Latino/a adolescent since 1990. Conceptual and methodological issues in research are examined and the role of contextual and developmental factors on suicide behavior is discussed. The empirical findings of comparative ethnic minority studies, studies focused on Latino/a youth, and within-group studies are reviewed. Research on Latino/a adolescent suicide behavior is limited, few studies focus on any Latino subgroup and it is rare to find comparative studies focus on within-group diversity among Latinos. For the most part, no explanatory variables that may account for the differences among groups or that help explain the meaning of the suicide behavior were found. Research efforts should move away from using generic labels (e.g., Hispanics, Latinos, etc.) and shift toward addressing group-specific (e.g., Mexican Americans, Puerto Ricans, etc.) findings that have implications for prevention and treatment of target populations (G. Canino & R. E. Roberts, 2001; J. D. Hovey & C. A. King, 1997). Suicide behavior studies among specific Latino/a adolescents that are based on theory and informed by ecodevelopmental, gender-specific perspectives should advance the field.

Dissociation, psychopathology, and abusive experiences in a nonclinical Latino university student group.

A variety of clinical and experimental data suggest that many individuals who report abusive and traumatic experiences also report a wide array of dissociative and other psychopathological symptoms. In this study, 198 Puerto Rican undergraduate students participated in a study to examine the possible relationship between different types of traumatic experiences and the self-report of dissociative experiences, depressive symptoms, and general psychopathology. Another aspect of this study was the examination of the psychometric properties of the Dissociative Experiences Scale (DES) in a Latino sample. Results supported the hypothesis that those individuals who reported frequent and severe traumatic experiences were also the most likely to experience psychological malaise and scored higher on the DES. Of interest was the finding that the psychometric characteristics of the DES are consistent with those reported in the United States and other countries. The authors conclude that individuals with a marked history of trauma and abuse are more likely to use dissociative defenses as a coping response.

Culturally adapted cognitive‐behavior therapy: integrating sexual, spiritual, and family identities in an evidence‐based treatment of a depressed Latino adolescent

The article described and illustrated how a culturally adapted cognitive-behavioral therapy (CBT) can maintain fidelity to a treatment protocol while allowing for considerable flexibility to address a patients values, preferences, and context. A manual-based CBT was used with a gay Latino adolescent regarding his sexual identity, family values, and spiritual ideas. The adolescent suffered from a major depression disorder and identified himself as gay and Christian within a conservative and machista Puerto Rican family. CBT promoted personal acceptance and active questioning of homophobic thoughts in a climate of family respect. CBT enabled identity formation and integration, central to the development of a sexual identity for lesbian, gay, bisexual, and transgender youth, with remission of the patients depression and better family outcomes.