One Size Does Not Fit All: Cultural Considerations in Evidence-Based Practice for Depression

How Do We Define Diverse Populations?

Before beginning our review of the literature, we first briefly explain our approach to conceptualizing diversity. Diversity in psychology is a broad term that refers to individual, personal, and collective identities, and life experiences across a variety of sociocultural constructs, including race, ethnicity, gender, social class, sexual orientation, religion, and disability. Indeed, scholars have written about all of these constructs as they relate to the application of psychotherapy with different populations. In this chapter, we focus on cultural diversity, a concept that touches on the terms culture, race, and ethnicity (Atkinson, Morten, & Sue, 1998; Helms & Cook, 1999). The term culture refers to a shared set of social norms, beliefs, and values that particular groups hold and transmit across generations. These norms, beliefs, and values are thought to be learned and cover a wide range of psychologically relevant topics, including gender and familial roles and relationships, styles of interpersonal communication, and philosophical world views (Betancourt & Lopez, 1993). The term race has historically tended to refer to physical or biological characteristics that distinguish particular groups of people from other groups (Atkinson, Morten, & Sue, 1998; Betancourt & Lopez, 1993). Although the existence of biological and genetic underpinnings of different racial categories have not been supported by recent biological and anthropological research (A. Smedley & B. Smedley, 2005), the term race nevertheless has social significance and meaning to individuals and is commonly used as a proxy for culture and ethnicity. Finally, the term ethnicity is generally used to refer to the historical cultural patterns and collective identities shared by groups from specific geographic regions of the world (Betancourt & Lopez, 1993; Helms & Cook, 1999). Some of these patterns include language, history, customs, and rituals.

Although the terms race, ethnicity, and culture have overlap, there are important distinctions among them (Alvidrez, Azocar, & Miranda, 1996; Betancourt & Lopez, 1993). For example, the racial category white includes individuals from different ethnic groups (e.g., individuals of British, French, Russian origin), which have different cultural customs. Further, individuals from the same ethnic group may have different cultural traditions depending on where they were raised (e.g., Asians growing up in Mainland China versus growing up in San Francisco).

In this chapter, we use the term culture instead of race or ethnicity when referring to diverse groups of individuals for whom an intervention has been adapted. Using the term culture is advantageous because it helps keep salient the fact that culture should be conceptualized as a multidimensional and contextual phenomenon that incorporates a variety of sociopolitical identities, including gender, socioeconomic status, and minority status. The use of the term culture can help remind us that it would be problematic to assume homogeneity in cultural worldviews among individuals from the same ethnicity but who vary in their gender, socioeconomic status, and experiences as a minority. This concern is particularly relevant to applying evidence-based practice (EBP) to diverse cultural groups because the overwhelming majority of cultural adaptations have been developed and evaluated with individuals from racial and ethnic minority backgrounds who also come from low-income backgrounds.

Research Evidence for EBP for Depression With Diverse Cultural Groups

There have been three recent reviews of evidence-based psychosocial interventions for racial and ethnic minorities. Each had a slightly different focus, but in general, the reviews found positive effects when examining the efficacy of evidence-based interventions with individuals from different cultural groups (Griner & Smith, 2006; Huey & Polo, 2008; Miranda, Bernal et al., 2005). With regard to depression in particular, several studies that included sufficient numbers of individuals from different cultural backgrounds have found support for the efficacy of cognitive-behavioral therapy (CBT) with Latinos and African Americans (Miranda, Azocar, Organista, Dwyer, Arean, 2003; Miranda, Chung et al., 2003; Miranda, Green et al., 2006; Organista, Muñoz, & González, 1994; Perez Foster, 2007). In addition, several studies that have focused on specific cultural groups have also found support for the efficacy of CBT with Latino adults and adolescents (Arean & Miranda, 1996; Comas-Diaz, 1981, 1986; Rosselló & Bernal, 1999; Rosselló, Bernal, & Rivera-Medina, 2008), African American women (Kohn, Oden, Muñoz, Robinson, & Leavitt, 2002), and elderly Chinese Americans (Dai et al., 1999). There also exists some support for the efficacy of CBT in the prevention of depressive symptoms among Latino adolescents (Cardemil, Reivich, Beevers, Seligman, & James, 2007; Cardemil, Reivich, & Seligman, 2002) and adults (Cardemil, Kim, Pinedo, & Miller, 2005; Le, Zmuda, Perry, & Muñoz, 2010; Muñoz et al., 1995; Muñoz et al., 2007; Vega, Valle, Kolody, & Hough, 1987).

In addition to CBT, there also exists support for the generalizability of interpersonal therapy (IPT) to Latinos and African Americans in the treatment and prevention of depression, the majority of which have been found with perinatal depression. Some of this work with pregnant women has been conducted with Latina women (Spinelli & Endicott, 2003), low-income and African American women (Crockett, Zlotnick, Davis, Payne, & Washington, 2008; Zlotnick, Miller, Pearlstein, Howard, & Sweeney, 2006), and low-income, Latina and African American adolescents (Miller, Gur, Shanok, & Weissman, 2008). In two studies that did not focus on perinatal depression, Rosselló and Bernal (1999) and Rosselló, Bernal, and Rivera-Medina (2008) also found support for the efficacy of IPT with Puerto Rican adolescents.

Taken together, the research evidence generally supports the efficacy of CBT and IPT with Latinos and African Americans. Unfortunately, the research base for the treatment and prevention of depression is significantly more limited for Asian Americans (one study of CBT for Chinese Americans) and nonexistent for individuals from other cultural groups, including American Indians. This lack of research into the generalizability of EBPs is changing, however, as there is increasing attention to the adaptations of EBPs for different cultural groups (e.g., Hwang, Wood, Lin, & Cheung, 2006; Jackson, Shmutzer, Wenzel, & Tyler, 2006; Renfrey, 1992).

Importantly, the majority of studies investigating the efficacy of CBT with different cultural groups have been variants on a series of manuals developed by Ricardo Muñoz and colleagues (Muñoz & Mendelson, 2005). These manuals were themselves based on the Coping with Depression (CWD) course initially developed by Lewinsohn and colleagues (Lewinsohn, Antonuccio, Breckenridge, & Teri, 1984; see Cuijpers, Muñoz, Clarke, & Lewinsohn, 2009, for an extensive review of the CWD course). Similarly, the studies that have focused on IPT have all based their work in the seminal work of Gerald Klerman, Myrna Weissman, and colleagues (Klerman, Weissman, Rounsaville, & Chevron, 1984; Weissman, Markowitz, & Klerman, 2000).

These studies have generally evaluated adapted versions of a standard intervention that the authors believe better address the needs of the target population. Some of the adaptations have been relatively minor, while others have been more comprehensive. It is also important to note that the majority of the cultural adaptations we reviewed have been developed for low-income populations (e.g., Kohn et al., 2002; Le et al., 2010; Miller et al., 2008; Miranda et al., 2003; Muñoz et al., 2007). As such, these cultural adaptations have necessarily dealt with issues of poverty and social class. In addition, many of the interventions also specifically targeted women and so attended to issues of gender in the development of their programs. In the following sections, we synthesize the different approaches to adaptation of a standard evaluation and provide concrete recommendations for clinicians interested in adapting and implementing an EBP for depression.

How Should EBP Be Adapted for Diverse Populations?

Although the attention to cultural adaptations of EBP has been increasing, there is no consensus regarding how to adapt EBP to clinical work with individuals from different cultural groups (Cardemil, 2008). For example, there are currently no clear guidelines as to when to adapt an intervention, for which specific populations an intervention should be adapted, the extent to which an intervention should be adapted, or how to evaluate the relative contribution of particular adaptations.

Recently, however, several scholars have offered frameworks for integrating cultural issues into evidence-based practice (Barrera & Castro, 2006; Bernal & Sáez-Santiago, 2006; Hall, 2001; Hwang, 2006; Muñoz & Mendelson, 2005; Whaley & Davis, 2007). One early cultural adaptation framework was developed by Bernal and colleagues (1995, 2006), who focused on ecological validity and rooted their approach in a contextualist perspective. Their framework emphasized eight different dimensions to which attention should be given when adapting, or centering, an intervention for a particular cultural group (for an in-depth discussion of these dimensions, see Bernal & Saéz-Santiago, 2006): (1) the language of the intervention; (2) metaphors to be used in the delivery of the intervention; (3) cultural knowledge about client values, customs, and traditions; (4) recognition and consideration of additional contextual influences in the client’s life; (5) the client-therapist relationship; (6) conceptualization and communication of the theoretical approach to treatment; (7) agreement on goals of treatment; and (8) methods for reaching goals of treatment. Attention to these eight dimensions would lead to an adapted intervention that is contextually relevant to the targeted population.

Our approach to adapting evidence-based practice to diverse cultural groups complements this approach, as well as others in the literature (Cardemil et al., 2010). In our depression prevention work with low-income, Latina mothers, we conceptualize culture as a multidimensional, contextual phenomenon that includes aspects of gender, socioeconomic status, and the larger systemic barriers our participants encountered in their daily lives. Thus, our cognitive-behavioral intervention incorporates aspects of four broad sociocultural domains: (1) Latino cultural values and life experiences, (2) gender and gender roles, (3) social class and economic stress, and (4) disempowerment in the form of discrimination and difficulty accessing needed social services. Concretely, our depression prevention program addresses and incorporates different aspects of Latino culture, issues relevant to women and mothers, the life experiences often found in urban, low-income neighborhoods, and the sense of disenfranchisement felt by many cultural minorities. Moreover, as with the other frameworks and approaches to cultural adaptation, our framework is necessarily flexible and does not assume that every participant has relevant life experiences with each of the four domains. Indeed, we have found significant variability in the extent to which individual participants resonate with different aspects of our attempts to incorporate diversity into our work.

Although the various frameworks in the literature have different perspectives and emphases, they share many commonalities, including the recognition that culture is a complex phenomenon that necessitates addressing diversity in many different ways. In our own work, we attended to three issues of diversity throughout the intervention, including (1) when making decisions regarding various structural aspects of the intervention, (2) in the delivery of the program, and (3) in the programmatic content of each of the sessions. Our review of the CBT and IPT literature suggests that these three areas were also the ones to which other research teams attended in their efforts to develop their cultural adaptations. We now describe each of these three domains in more detail.

Diversity Considerations in the Structure of the Intervention

When clinicians and researchers implement an intervention, they need to consider how the intervention should be organized so as to provide the best therapeutic effect. Some general structural considerations include whether the intervention should be delivered individually or in group format, the number and frequency of sessions, the ordering in which content is presented to participants, and the inclusion of extra-session homework.

Attending to diversity should also take place at the structural level, and many of the interventions we reviewed made explicit structural adaptations to standard 16-session CBT. For example, in one study evaluating CBT with low-income, minority women, Miranda and colleagues (2003) added educational information sessions prior to the intervention in order to help some of the women make informed decisions about whether or not to initiate treatment for depression (Miranda et al., 2003). These sessions were developed in recognition of the variability that exists in many cultures’ conceptions of health and illness, and they served as a bridge between the authors’ conceptions of depression and treatment and the women’s own conceptions. In another study that focused on treating depression among low-income primary care patients with CBT, Miranda and colleagues (2003) added supplementary case management to the CBT (Miranda, Azocar, Organista, Dwyer, & Arean, 2003). The purpose of the case management was to help maintain high levels of engagement with the patients in the study. In addition, the case management also focused on helping the patients cope with ongoing life stressors, many of which were related to their low-income status. Some of these stressors included problems in housing, employment, recreation, and relationships with family and friends.

Several of the studies we reviewed made the explicit structural decision to deliver the intervention in group format (e.g., Cardemil, Kim, Pinedo, & Miller, 2005; Comas-Diaz, 1981; Kohn et al., 2002; Miranda et al., 2003; Muñoz et al., 1995; Rosselló, Bernal, & Rivera-Medina, 2008). The use of group approaches appeared to emphasize the development of group cohesion around similar culturally relevant life experiences. Interestingly, some of the approaches limited participation to individuals from a single cultural group (Cardemil et al., 2005; Comas-Diaz, 1981; Kohn et al., 2002), while others included individuals from different cultural groups (Cardemil et al., 2002; Muñoz & Mendelson, 1995; Organista, Muñoz, & Gonzalez, 1994; Satterfield, 1998). There also existed variability in whether the groups were open to ongoing enrollment by participants. For example, Miranda and colleagues (2003) used an open group format in which new participants joined ongoing groups at the beginning of one of three four-week modules. These authors noted that this approach made the intervention more feasible for ongoing medical referrals. Several other research teams also used this open-group approach (e.g., Organista et al., 1994; Satterfield, 1998). In contrast, a few other research teams explicitly used a closed-group approach with the aim of enhancing group cohesion among the participants (e.g., Cardemil, Kim, et al., 2005; Kohn et al., 2002).

Several research groups who focused on Latinos addressed the importance of family within Latino culture through explicit structural adaptations. For example, in their evaluation of CBT and IPT with Puerto Rican adolescents, Rosselló and Bernal (1999) incorporated a parental interview before and after therapy. This interview allowed the therapist to acknowledge the importance of family obligation and support, the traditional hierarchical nature of Puerto Rican families, and the dependence on parents for instrumental and emotional support. Therapists were allowed to discuss treatment issues with the parents, although confidentiality was guaranteed to the adolescents. Similarly, in our work we explicitly incorporated family sessions into our group prevention work with Latina mothers (Cardemil et al., 2005; Cardemil et al., 2010). The purpose of these family sessions was to welcome participants’ families into the treatment process, demystify our intervention, and enlist family members into supporting the participant. We used a broad definition of family, which encouraged participants to invite intimate partners if possible, but allowed participants to invite other important adults if preferred. This flexibility allowed us to take advantage of the extended-family structure that is commonly found in Latino families (Falicov, 1998; Gloria, Ruiz, & Castillo, 2004) as well as helping the significant numbers of single mothers feel welcome in our intervention.

In sum, our review of the literature produced many innovative approaches to adapting the structure of the intervention. These efforts are creative in that they extend the traditional conception of psychotherapy beyond the 50-minute therapy hour so as to best reach different cultural groups. Complementing these structural changes is the attention researchers give to the delivery of the intervention, both regarding how therapists interact with the clients and the flexibility in the scheduling of sessions. We now describe these considerations in more detail.

Diversity Considerations in the Delivery of the Intervention

In adapting and applying evidence-based practice to diverse populations, researchers have also focused on the manner in which their intervention has been delivered. A few of the studies we reviewed thought creatively about the location in which the intervention would be delivered and made the decision to hold the intervention in a nonclinical setting. For example, Miller and colleagues (2008), in their prevention and treatment work for postpartum depression among adolescents, held their IPT intervention in school during health classes. Similarly, Cardemil, Reivich, and colleagues (2002, 2007) implemented their CBT depression prevention program during school hours. Holding interventions during school hours has the obvious advantage of making the intervention highly accessible to the participants, normalizing the discussion of mental health topics, and increasing the likelihood that participants feel comfortable.

One innovative approach to this issue was conducted by Vega, Valle, Kolody, and Hough (1987) in their delivery of a cognitive-behavioral depression prevention intervention for Latina women. In their work, rather than use therapists to deliver their intervention in a clinical setting, they used servidoras, or indigenous Latina community helpers, and delivered the intervention in community settings. This approach, which has been used in other prevention-oriented health work, is striking in its use of existing community social networks to increase the reach of the intervention.

Researchers have also spent considerable time focusing on therapist behavior when they adapt EBP for diverse populations. Much of this focus has been on having therapists attend to relevant cultural values when interacting with clients. For example, Hwang and colleagues (2006) suggest that clinicians can gain credibility with their Chinese clients by taking into account the importance placed in the Chinese culture on hierarchical relationships, social harmony, and respect for authority figures. Thus, they recommend that therapists present themselves as authority figures with the ability to help their clients solve problems. They also suggest that therapists be proactive in the provision of direction, advice, and teaching skills for symptom relief.

Some of these recommendations are similar to those that have been made when working with individuals from other cultural groups. For example, some researchers have suggested that in American Indian communities, traditional healing practices encourage clients to take on a passive role in deference to the expert healer (Dinges, Trimble, Manson, & Pasquale, 1981). This passive role would encourage a more active, directive approach by the clinician, although as Renfrey (1992) warns, an overly directive style can run the risk of positioning the clinician as a controlling agent of the dominant culture.

With regard to working with Latinos, various scholars have written about the use of certain important Latino values, including personalismo, respeto, and familismo (e.g., Muñoz & Mendelson, 2005; Rosselló & Bernal, 1999). In our own group work with low-income Latinas, we also used these three values in order to gain traction for the delivery of our prevention program. Throughout the intervention, leaders strove to maintain a friendly and relaxed environment so as to sustain an air of personalismo, which refers to the emphasis on close interpersonal relationships. This was accomplished in various different ways, namely through self-disclosure, through diffusion of the expert role to include the participants as a source of expertise, and through the provision of food during the sessions. One good example of how self-disclosure can lead to increased rapport with group members can be seen in this exchange following the self-introduction of one of the group leaders:¹

Group Leader (GL): Good morning, everyone. My name is Suzette, and I am Venezuelan and I have lived in this country for about 13 years. In that respect, English is my primary language now because I have been using it since I was 12.

Alma (A): I’m sorry; I believed that you were from here.

GL: No, don’t worry. Everyone thinks that. I am Venezuelan, I was born there and was raised there up until I was 11 or 12. My family then moved to the United States. So, yes, sometimes I forget my Spanish because that is what happens when you do not use the language all that often. So, at times I’m going to make a mistake, so please have patience with me and help me, please.…

A: My children tell me the same thing, because my children came to this country when they were young.

GL: Uh hum.

A: My littlest tells me, he says, “Momma, I am forgetting Spanish” and I tell him not to forget because to speak two languages, one counts for two.

By expressing some vulnerability regarding her Spanish-speaking ability, the group leader reduced some of the distance that commonly exists between therapists and clients. Moreover, the exchange led one of the participants to describe a commonly experienced culturally relevant stressor for Latinos: namely, the desire to have one’s children speak Spanish and be connected to one’s culture of origin.

This effort to maintain personalismo is integrated throughout different facets of our intervention, but it is also tempered by the Latino value of respeto—the emphasis on showing respect and differential behavior to others. This is done in several ways, but most obviously through the use of formal language (e.g., using the formal usted and not the informal tu when addressing participants and family members in the second person).

It is important to remember that attention to therapist behavior should not be limited to cultural values. Rosselló and Bernal (2005) describe their attention to issues of poverty among their population. They note that the therapists in their study were sensitized to the economic, racial, and cultural diversity in their clients as well as to the different ways of living that may result from this diversity. They also encouraged therapists to discuss socioeconomic and racial differences with their clients should the need arise. Similarly, we are cognizant of the ways that socioeconomic stress places significant competing demands on many of our participants’ schedules (e.g., multiple jobs, various appointments with different social service agencies, transportation difficulties). Thus, we attempt to schedule appointments flexibly, including in the early morning and evening hours as well as on weekends. We also offer bus passes or taxi vouchers to all participants and provide on-site childcare for those participants who need it.

Diversity Considerations in Program Content

In addition to creatively modifying the structure and the delivery of the intervention, efforts to evaluate the generalizability of interventions with different cultural groups invariably also adapt the content of the program. In our review of the literature, we found two main approaches to incorporating diversity issues into program content. Some research teams adapt the intervention manuals to explicitly include modules that address culturally relevant themes. An excellent example of this approach can be seen in the work of Laura Kohn and colleagues (2002), who adapted a cognitive behavioral group treatment for use with depressed low-income African American women. In addition to the standard cognitive-behavioral modules on cognitions, activities, and relationships, these authors added four culturally specific sessions: (1) creating healthy relationships, (2) spirituality, (3) African American family issues, and (4) African American female identity. Of note is that these additions were grounded in the theoretical and clinical research as well as in interviews with therapists who had worked with African American women.

In addition to this approach, many of the adapted interventions modified the material in the manuals that highlighted particular emotion-regulation skills and problem-solving approaches. This standard material often takes the form of stories, didactic exercises like worksheets, and interactive role-play exercises that make the thematic and didactic material more accessible to the clients. This material is usually located in the therapist and participant manuals, with the intention of being used as both in-session work and homework. The cultural adaptations of this material typically consist of highlighting and working through culturally relevant life stressors, including immigration and immigration-related stress, experiences with prejudice and discrimination, and interfamilial stress related to acculturation (e.g., Cardemil et al., 2005, 2010; Muñoz & Mendelson, 2005). Several interventions also emphasized including material that highlighted stressors associated with urban poverty, including exposure to violence, difficulty accessing services, and financial stress (Cardemil et al., 2002, 2007; Miller et al., 2008). Other authors found ways to incorporate spirituality and religion into the intervention (Kohn et al., 2002; Muñoz & Mendelson, 2005). Le, Zmuda, Perry, and Muñoz (2010) describe their use of hand-drawn stories that resembled telenovelas, or soap operas, to describe how one’s choices can influence one’s mood and well-being.

In our depression-prevention program for Latina mothers, for example, we utilize commonly experienced difficult decisions to build rapport and cohesion among the participants. We begin this process early in our first group session by asking our participants to generate a list of difficult experiences related to being a Latina mother. One commonly cited difficulty that participants have mentioned is not being able to communicate with their children’s school personnel because of their inability to speak English well. In one group we led, the participants were somewhat quiet, providing relatively short answers to questions from the group leader. However, when one of the participants mentioned not being able to communicate with her child’s school teacher, other participants became more engaged in the discussion, sharing their experiences and relating to one another. This conversation unfolded as follows:

Group Leader (GL): What are some other difficulties related to being a Latina mother?

Julia (J): Not knowing English, so I can’t communicate with my child’s school.

GL: Has that happened to anybody else?

Erica (E): Yes. It is very difficult when all you know is Spanish and in school the teachers speak English.

Isabel (I): Before, I had this problem. I could not communicate because I only knew a little bit of English. Now, I know more English, so it is not as difficult.

J: A lot of times, [my children] serve as interpreters. They can dominate the language better.

E: That is true; my son is always my interpreter.

GL: So your children help you then?

I: Yes.

J: Yes. He helps me with my writing and I always ask him for help when I need it.

E: I also ask my child for help with English.

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