The Cultural Adaptation of Treatments in Counseling Settings

Equality, while fundamental to our way of life, is insufficient when implementing treatment approaches for people who use substances. Instead, more focus should be on equity, or ensuring that an individual/population has the necessary resources to be successful. The US population has experienced increasing diversity over the past decade, and this diversity also extends to individuals served within substance use treatment settings.

The National Survey of Drug Use and Health (NSDUH) reported that in 2018, 88.7 percent of African American individuals aged twelve and older with substance use disorders (SUDs) did not receive treatment (SAMHSA, 2020). Additional research has demonstrated that, once in treatment, African Americans are less likely to complete treatment compared to their white counterparts (Mennis & Stahler, 2016; Saloner & Cook, 2013). Saloner and Cook (2013) suggest that this discrepancy is partially due to a lack of cultural sensitivity that may negatively influence treatment engagement. This variance in treatment engagement and completion between whites and racial/ethnic groups requires more attention to ensuring that evidence-based treatments perform optimally among the different groups.

While the empirical support backing evidence-based treatments increases their appeal, counselors have likely observed that “one size” does not “fit all” in their clinical work. Several reasons may explain why generic versions of evidence-based interventions fail to address the culture-specific needs of racial/ethnic groups. First, generic treatment approaches have long focused on casting the widest net possible, reaching people from all groups with one protocol rather than focusing on specific subgroups. Second, the representation of racial/ethnic populations in research evaluating evidence-based treatments is frequently so small that the effectiveness and generalizability of evidence-based treatments for these populations cannot be assumed. Third, generic interventions typically do not address unique cultural or contextual factors associated with either the target behavior or responses to the treatment. Finally, including members of a specific target group or utilizing the available knowledge base of that target population could result in a more effective intervention for that group. However, frequently neither are included in protocol development.

Cultural adaptation is a way of addressing the limitations of evidence-based treatment. Counselors are well-positioned to play a pivotal role in culturally adapting evidence-based treatments for underserved communities. However, despite available information on the benefits of modifying treatments for diverse populations, concrete methods for counselors to adapt interventions are limited. The goals of this article are to highlight the intersection of evidence-based practice and cultural competence by describing three models of cultural adaptation, and to provide examples of how these models can be implemented in clinical settings. The subsequent sections of this article will review cultural adaptation, highlight three adaptation models, and finally discuss the practicalities of implementing each cultural adaptation model in clinical settings.

Cultural Adaptation

The objective of cultural adaptation is to increase the effectiveness of an evidence-based treatment by modifying either its presentation or content to be more relevant and consistent with the values, beliefs, norms, attitudes, and knowledge of a specific target group (Bernal, Jiménez-Chafey, & Domenech-Rodríguez, 2009; Copeland, 2006; Falicov, 2009). Deciding when adaptation is required is a considerable challenge for counselors. Lau (2006) suggests that adaptation is appropriate when a treatment does not engage a specific target group, when a target group has unique risk or resilience factors or symptoms, and especially when the treatment is not demonstrating effectiveness in a target group.

An impressive body of work suggests that cultural adaptation has the potential to improve treatment effectiveness. Several meta-analyses of multiple studies support the advantage of cultural adaptation (e.g., Griner & Smith, 2006; Hall, Ibaraki, Huang, Marti, & Stice, 2016; Huey & Polo, 2008; Smith, Domenech-Rodríguez, & Bernal, 2011). Furthermore, studies of specific evidence-based interventions for both treatment (Longshore & Grills, 2000) and prevention (Botvin & Scheier, 1997; Calsyn et al., 2013; Spoth, Guyll, Chao, & Molgaard, 2003) have demonstrated the effectiveness of culturally adapted versus generic versions of the same treatments.

The ecological validity (EVF; Bernal & Adames, 2017; Bernal & Sáez-Santiago, 2006) and the cultural sensitivity (CSF; Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000) frameworks are two early approaches to cultural adaptation. The EVF contends that adapting may involve altering the language, persons, metaphors, content, concepts, goals, methods, or context. The CSF framework differentiates between surface adaptations that modify the presentation (e.g., the language and/or ethnicity of the facilitators) but not the core concepts of the curriculum, and deep structural adaptations that retain the core components but supplement the curriculum to incorporate the culture, social experiences, and values of a particular racial/ethnic group. A number of other models have emerged, including the cultural adaptation process model (CAPM; Domenech-Rodríguez & Wieling, 2005), culturally specific prevention (Whitbeck, 2006), heuristic framework (Barrera & Castro, 2006), formative method for adapting psychotherapy (Hwang, 2009), and the method for program adaptation through community engagement (M-PACE; Chen, Reid, Parker, & Pillemer, 2013).

The following sections present three models that counselors might utilize to improve the effectiveness of interventions through cultural adaptation. First we illustrate clinical and academic professionals serving as experts using the Delphi process. Next we describe the inclusion of community members in the adaptation process using theater testing. Finally, we describe a model in which community partners are full members of the team (i.e., sharing decision-making responsibility and power) through community-based participatory research (CBPR). In the discussion, we explore the limitations and strengths of each model.

Model One: The Delphi Process

The Delphi process is a structured process for pooling expert opinions to achieve consensus on a specific question (e.g., how best to culturally adapt an intervention). The process typically unfolds in a series of rounds (de Villiers, de Villiers, & Kent, 2005). After determining criteria for agreement and disagreement, the investigators typically recruit an expert panel to provide structured responses. In the normal course of events, experts in a conventional Delphi process work independently to avoid the possibility that higher-status individuals have more influence on the final outcome. The investigative team collates the ratings and other information. Next, the team develops a second document that incorporates the round-one feedback and sends the new document back out to the experts for a second review. The process ends if the experts reach consensus during the second round. If not, however, additional rounds can be added until consensus is reached.

We utilized a version of the Delphi process to culturally adapt Real Men Are Safe (REMAS), a National Drug Abuse Treatment Clinical Trials Network (CTN) intervention for reducing HIV risk behaviors among men who use substances. Donald Calsyn, the investigator who developed REMAS, and his colleagues observed that although the Centers for Disease Control and Prevention (CDC) included REMAS on its compendium of evidence-based interventions, REMAS was not as effective for African Americans and other racial/ethnic minorities as it was for white men (Calsyn et al., 2012). One of the authors of this article (Burlew) joined Dr. Calsyn’s group for the cultural adaptation. Calsyn’s group first identified four other culturally tailored, HIV-risk-reduction interventions for men (Calsyn et al. 2012). These interventions did not necessarily target people who use substances, but were aimed at reducing HIV and included modules that matched the REMAS content. For example, both REMAS and another intervention might include modules on HIV education or on correct condom use.

Next, the team recruited experts (i.e., researchers and clinicians with knowledge of HIV among the African American community) who agreed to assist in the adaptation. The team first asked the experts to review materials on surface versus deep structural modifications. Afterwards, along with suggesting ideas for modification, the experts rated modules in REMAS and corresponding modules in the four other culturally tailored HIV interventions from low (one) to high (five) on the following criteria:

• Use of the language and expressions of the target group
• Inclusion of activities that enhance ethnic identity
• Consistency with norms, knowledge, and cultural values of the target group
• Demonstration of an understanding of the social context that surrounds the behavior and living situation of the target group

When the expert ratings for specific REMAS modules were high on the aforementioned criteria, cultural adaptation was considered unnecessary regardless of the ratings of the corresponding modules from other interventions. However, when the REMAS ratings were low, the team reviewed the suggestions from the experts and the corresponding modules from other interventions with higher ratings for ideas on how to adapt REMAS modules in the culturally adapted version.

The team sent only the culturally adapted version of the full REMAS back to the experts—not the other interventions—in round two. In our case, the experts rated the culturally adapted version as satisfactory. However, if experts had rated the modules as needing further adaptation, the Delphi process calls for a third round.

The differences between the generic and the culturally adapted versions of REMAS are described in more detail elsewhere (Burlew, McCuistian, Lanaway, Hatch-Maillette, & Shambley-Ebron, 2020; Calsyn et al., 2012). However, the culturally adapted version not only includes surface changes of the language and recommends the recruitment of facilitators from the racial/ethnic group, but also includes the addition of deep structural changes in the curriculum to better reflect the cultural context of sexual behavior among men of color.

We piloted the culturally adapted version in a small, four-city study (Calsyn et al., 2013). The results revealed that racial/ethnic participants in the culturally adapted version (relative to the generic version) attended more sessions, reported fewer casual partners, and engaged in fewer unprotected sexual occasions with casual partners.

Model Two: Theater Testing

Theater testing, a process developed by Wingood and DiClemente (2008) in their ADAPT-ITT model, is the second model for cultural adaptation. Theater testing has three main components: mock demonstration of the intervention involving the target population, experts observing the mock demonstration, and feedback from participants and experts. These three components work together to provide information for how and what should be adapted within the intervention to render it more appropriate for the target group. The process for cultural adaptation using theater testing begins by conducting a mock demonstration of a generic intervention. During this implementation, members of the target group serve as mock participants. Simultaneously, the adaptation team recruits experts to observe the mock intervention as it is being conducted. Subsequently, both the target group participants and the experts provide feedback at various points throughout the mock demonstration. After gathering feedback from the mock demonstration of the generic intervention, the team adapts the protocol. A second mock demonstration is then completed using the adapted protocol with new target group members. The team gathers feedback again to ensure the modifications were sufficient. If needed, the theater testing procedure can be conducted an additional time, now using a new group of mock participants and making any additional and appropriate adaptations. This process can be completed as many times as needed until no further modifications are necessary.

The following is an illustration of how we utilized theater testing to culturally adapt Safer Sex Skills Building (SSSB), another CTN intervention developed to reduce sexual risk behaviors among women who use substances (Tross et al., 2008). This project incorporated both counselors and academic researchers to serve as experts. Researchers possessed in-depth knowledge of relevant scientific literature and other related interventions that guided feedback, while counselors in a residential substance use treatment facility aided with recruitment of participants for the target group (e.g., African American women). The team first conducted a mock demonstration of the generic SSSB intervention with a group of African American women in substance use treatment. Both academic and clinical experts, including counselors, observed the mock demonstration and experts as well as target group members provided the feedback that guided the cultural adaptation.

The adapted version included both surface and deep structural changes. Surface adaptations included adjusting the language to be more culturally relevant, such as referring to the intervention as a “program,” using names in scenarios that are common within the African American community (e.g., “Keisha”), and utilizing African American facilitators (i.e., person adaptations). The deep structural changes added curriculum on the social context for African American women, such as modules on navigating partner violence and examining gender roles around sex and relationships in the African American community. Together, all of the adaptations produced a new version of the intervention that underwent a second mock demonstration with new target group member participants and was deemed to be more appropriate for African American women who use substances. A small pilot study revealed that participants who completed the culturally adapted SSSB were more likely to have used a condom during their most recent vaginal sexual intercourse than those who completed the generic version.

Model Three: Community-Based Participatory Research (CBPR)

The integration of evidence-based interventions into substance use treatment has often been challenging due to barriers related to implementation and sustainability (Damschroder & Hagedorn, 2011). One possible cause of these barriers is the lack of a fit between the intervention and the target group. Involving community members in the intervention process is one way to address these barriers (Kwon, Tandon, Islam, Riley, & Trinh-Shevrin, 2018). Community-engaged research such as community-based participatory research (CBPR) is an orientation to research that encourages full partnership between community and academic members in all phases of the research process (Rhodes, Malow, & Jolly, 2010). Research conducted using a community-engaged approach leverages the knowledge and expertise of both community and academic members and can directly target community needs, often resulting in more culturally relevant interventions (Jacquez, Vaughn, & Wagner, 2013). This in turn has a positive impact on outcomes and sustainability. Partnerships that involve service providers such as counselors, social workers, therapists, and academic researchers have been successfully developed in the past (Garland & Brookman-Frazee, 2015; Spector, 2012). Partnerships have also successfully included members of the group that the intervention is targeting. These partnerships are well positioned to address specific community issues, including substance use. Additionally, when involved in research, service providers are more likely to integrate evidence-based findings into clinical care later (Pinto, Yu, Spector, Gorroochurn, & McCarty, 2010). Thus, community-engaged research could be a helpful strategy when developing culturally adapted interventions.

These partnerships have the advantage of benefiting from the unique expertise of counselors, researchers, and members of the target group. Counselors are often more aware of the needs of their clients, which could result in an adapted version of the intervention that is a better fit for the target group. Counselors may also have easier access to hard-to-reach communities that may have limited access to evidence-based interventions. Conversely, researchers have expertise in the scientific aspects of treatment development and cultural adaptation. Researchers also may have more time to dedicate to technical aspects of cultural adaptation, while some counselors may view this time commitment as a barrier. In addition to counselors and researchers, members of the target group can also serve as community partners. These individuals can assume several roles, from identifying community/target group needs to providing feedback regarding how the intervention maps onto their cultural norms and values, to becoming full partners on all phases of the process. Such collaborations are often referred to as CBPR.

CBPR is defined as “an approach that ensures community participation in research,” and that it “. . . establishes structure for full and equal participation in research by community members (including those that are affected by the issue being studied), organizational representatives, and academic researchers to improve community health and well-being” (Rhodes et al., 2010, p. 174). Wallerstein and Duran (2010) highlighted several issues preventing intervention research from being easily translated into clinical practice, such as issues with external validity, interventions using language unacceptable within the community, or a lack of trust between community and professionals among underrepresented populations. These authors suggest that CBPR can be used to address these issues through core principles such as gaining a better understanding of the community, building sustainable relationships with community members, and engaging with community stakeholders in shared decision making.

In order to demonstrate the application of CBPR to cultural adaptation, we present a study that developed a partnership between women in substance use treatment and academic researchers that also received support from a substance use counselor. The partnership developed an intervention aimed at supplementing SSSB by addressing the issues regarding safe sex that substance-using women who are engaged in transactional sex (i.e., the trade of sex for drugs, money, or other material incentives) may face. Along with a counselor serving substance-using women, the partnership consisted of five target group members (i.e., women in substance use treatment with a reported history of transactional sex), two academic members, and an undergraduate student. The partnership met for four, four-hour meetings to develop the intervention and determine implementation strategies. During the initial meetings, the partnership identified project goals, examined the needs of substance-using women with a history of transactional sex, and reviewed previous literature. In the final meetings, the partnership identified a community-driven definition of transactional sex and developed a tailored intervention session. This study resulted in an intervention for substance-using women engaged in transactional sex that, due to its alignment with the needs of the target group, is likely to minimize any potential implementation barriers.

Discussion

As presented in this article, several models of culturally adapting interventions are available. However, each model has its own advantages and limitations that counselors may consider when determining which method is most appropriate for their cultural adaptation. When making this decision, counselors often weigh several factors, including the available resources, the urgency of creating an adapted version, and the time that counselors, academic researchers, and target group members can devote to the adaptation. The expertise of counselors, researchers, and target group members can be leveraged to ensure the success of any of the methods.

The Delphi process has several challenges. Since the experts never communicate with each other, the independent process does not allow for ideas and suggestions that might emerge from group synergy. Although not an official component of the Delphi, assembling the experts after they submit their final ratings for additional feedback may be a strategy for capturing that synergy. Perhaps the most significant Delphi challenge is that requiring the experts to read and evaluate the content may limit the selection of experts to individuals accustomed to engaging in such an academic endeavor. To overcome this challenge, the Delphi process may require modification to utilize procedures more accessible to experts who either have low literacy levels or are unlikely to engage in a task that requires extensive reading. For example, creating video clips of modules for such experts to review and evaluate may be more feasible. Despite the challenges, the Delphi process also has several advantages. First, the fact that the experts work independently overcomes the tendency for the opinions of certain higher-status group members to outweigh the opinions of others in a group setting. Furthermore, experts have more time to think through their responses before submitting their ratings. In addition, the independent process allows for recruitment of experts from across the nation rather than limiting the experts to those available for face-to-face contact.

When culturally adapting using the Delphi process, the extensive knowledge of the target group that counselors possess would undoubtedly prove useful if they serve as experts. Counselors may also be able to assist in identifying other experts who are also aware of the needs of the target group.

Some challenges also exist in using theater testing in a clinical setting. For instance, theater testing is more time consuming and potentially costlier than using the Delphi process. Target group members, although providing feedback during the mock demonstrations, are not involved in decision making. Despite these challenges, theater testing has several strengths for adaptation. This process involves members from the target group, something missing in our illustration of the Delphi process. Including target group members in intervention development may ensure that the content and delivery of the intervention are more applicable to the target group than adaptation methods that do not include some form of community engagement.

Counselors can also hold an important role when utilizing the theater testing model of cultural adaptation. For example, counselors may be aware of the best method of identifying and recruiting target group members to serve as mock participants. These target group members may also feel more comfortable providing frank feedback with counselors or other community members present.

CBPR is also not without limitation. First, while developing partnerships with members of the target group (i.e., substance-using women with a history of transactional sex) is unique, several barriers could occur. For example, retention of the target group members can be difficult over the span of the project. Furthermore, developing such a partnership is often time consuming and costly. Obtaining institutional approval (e.g., required human subjects training) to conduct CBPR research can also be a tedious task. Despite these limitations, CBPR has several advantages over traditional methods. For example, CBPR can potentially result in an adapted intervention that addresses the unique needs of the target group. Due to this, CBPR holds noteworthy promise for improving the efficacy of treatments and the sustainability of the intervention.

As members of a partnership, counselors can be involved in multiple ways when using CBPR to culturally adapt. For example, counselors can participate in colearning with academic researchers. They can share in decision making for the design of the adapted version. Counselors may also be well positioned to engage target group members to join the partnership.

We encourage counselors and other clinicians to consider any of these models when deciding to culturally adapt current interventions. The decision to culturally adapt will likely be informed by several variables, including the perceived need for an adapted version, counselors’ interest and bandwidth to dedicate time to cultural adaptation, and available resources. In order to determine which method is most appropriate, counselors may choose to form a collaboration with community members and/or local academic researchers. Many universities often include information about researchers interested in community research on their directory websites. Counselors can also explore information about federally funded grants (e.g., Patient-Centered Outcomes Research Institute) that support community-based research.

Summary

Counselors can play a pivotal role in modifying treatments and interventions to increase effectiveness with different target groups. We have described three different models for cultural adaptation. We encourage counselors in collaboration with academic partners and target group members to select the most appropriate model for their setting.

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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:

• Burlew, A. K., McCuistian, C., Lanaway, D., Hatch-Maillette, M., & Shambley-Ebron, D. (2020). One size does not fit all: A NIDA-CTN-inspired model for community engaged cultural adaptation. Journal of Substance Use Treatment, 112, 28–33.

Ann Kathleen Burlew

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Ann Kathleen Burlew, PhD, is a professor emeritus of psychology at the University of Cincinnati. She is the coauthor/co-editor of four books and has published over seventy journal articles and book chapters. Dr. Burlew previously served as the editor-in-chief of the Journal of Black Psychology and is currently an associate editor of the Journal of Ethnicity in Substance Abuse. As a psychological consultant for a substance abuse clinic for over twenty-five years. she has trained multiple students in substance abuse treatment and prevention. In her role as chair of the Minority Interest Group of NIDA’s National Drug Abuse Treatment Clinical Trials Network, Dr. Burlew has been involved in culturally adapting evidence-based treatments to be more appropriate for different target groups.

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Caravella McCuistian

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Caravella McCuistian, PhD, is currently a clinical psychology postdoctoral fellow at the University of California, San Francisco. She received her doctoral degree in psychology from the University of Cincinnati. Dr. McCuistian’s research interests include addressing health disparities among underserved populations including racial/ethnic minorities, women, individuals living with HIV, and substance-using populations. She has conducted research that utilizes community-engaged methodology, including community-based participatory research.

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Danni Lanaway

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Danni Lanaway, PhD, completed her doctoral degree in clinical psychology at the University of Cincinnati and is currently employed at the Atlanta VA Medical Center. Her research has focused on psychosocial factors that influence substance use as well as the cultural adaptation of psychosocial interventions. In both her research and clinical work, Dr. Lanaway serves underrepresented and minority populations, with the goal of providing culturally relevant care to target and reduce mental health disparities.

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