Cultural Adaptation of Treatments: A Resource for Considering Culture in Evidence-Based Practice
There is a growing interest in whether and how to adapt psychotherapies to take into account the cultural, linguistic, and socioeconomic context of diverse ethnocultural groups. At the root of the debate is the issue of whether evidence-based treatments (EBTs) developed within a particular linguistic and cultural context are appropriate for ethnocultural groups that do not share the same language, cultural values, or both. There is considerable evidence that culture and context influence almost every aspect of the diagnostic and treatment process. Yet, there are concerns about fidelity of interventions, and some have questioned whether tinkering with well-established EBTs is warranted. We present arguments in favor of the cultural compatibility and universalistic hypotheses. Next, we review the available published frameworks for cultural adaptations of EBTs and offer examples from the literature on the process and outcome of different approaches used. Conceptual models for adapting existing interventions and emerging evidence that adapted intervention leads to positive outcomes suggest that there are tools for engaging in evidence-based psychological practices with ethnocultural youth. Recommendations for future directions are provided. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Cultural Adaptation of Treatments:
A Resource for Considering Culture in Evidence-Based Practice
Guillermo Bernal and Marı´a I. Jime´nez-Chafey
University of Puerto Rico, Rio Piedras
Melanie M. Domenech Rodrı´guez
Utah State University
There is a growing interest in whether and how to adapt psychotherapies to take into account the cultural,
linguistic, and socioeconomic context of diverse ethnocultural groups. At the root of the debate is the
issue of whether evidence-based treatments (EBTs) developed within a particular linguistic and cultural
context are appropriate for ethnocultural groups that do not share the same language, cultural values, or
both. There is considerable evidence that culture and context influence almost every aspect of the
diagnostic and treatment process. Yet, there are concerns about fidelity of interventions, and some have
questioned whether tinkering with well-established EBTs is warranted. We present arguments in favor of
the cultural compatibility and universalistic hypotheses. Next, we review the available published
frameworks for cultural adaptations of EBTs and offer examples from the literature on the process and
outcome of different approaches used. Conceptual models for adapting existing interventions and
emerging evidence that adapted intervention leads to positive outcomes suggest that there are tools for
engaging in evidence-based psychological practices with ethnocultural youth. Recommendations for
future directions are provided.
Keywords: evidence-based treatments, ethnic minorities, cultural adaptation, youth
Clinicians have long known that the best treatment is one that is
personalized to the needs and context of the individual. Yet, with
the increased focus on empirical information regarding treatment
development, efficacy, or effectiveness, the past two decades have
been marked by efforts to achieve uniformity in providing care to
a broad base of clients. Promoting a systematic approach to treat-
ment is a double-edged sword; on one hand, greater structure for
researchers and practitioners and a call for accountability for
treatment and research procedures are attractive features for those
who espouse a scientist–practitioner model to psychological prac-
tice or training. On the other hand, such systematization can
potentially increase the risk of adopting a one-size-fits-all ap-
proach to interventions and intervention research that is contrary in
practice to what the movement intended to promote in spirit (i.e.,
competent practice). Achieving a balance between culturally com-
petent practice and selection of interventions that are scientifically
rigorous is especially challenging when delivering interventions to
ethnocultural groups (ECGs).
The balance may be achieved elegantly through the use of
cultural adaptation procedures. We define cultural adaptation as
Editor’s Note. This article is one of four in this special section on
Evidence-Based Practice and Multicultural Populations.—MCR
GUILLERMO BERNAL received his doctorate from the University of Massa-
chusetts at Amherst. He is a professor of psychology in the Department of
Psychology, University of Puerto Rico, Rı´o Piedras, and is the director of the
Institute for Psychological Research. His research, training, and practice in-
terests are mental health treatments, interventions, and services responsive to
ethnocultural groups, particularly adolescent depression, family processes, and
dissemination of effective interventions. He is also interested in program
development and evaluation for research training and mentoring.
ARı´A I. JIM
ENEZ CHAFEY received her doctorate in clinical psychology
from Carlos Albizu University in San Juan, Puerto Rico. She is a staff
psychologist in the Department of Counseling for Student Development,
University of Puerto Rico, Rı´o Piedras. She also collaborates with the
Institute for Psychological Research at the University of Puerto Rico. Her
professional and research interests include depression treatment and pre-
vention, comorbidity in psychological disorders and metabolic diseases,
health psychology, suicide intervention and prevention, cultural adaptation
of psychological interventions, and couples’ violence in intimate dating
ELANIE M. DOMENECH RODRı´GUEZ received her doctorate in psychology
from Colorado State University. She is an associate professor in the
Department of Psychology, Utah State University. Her research, practice,
and teaching interests are in Latino–Latina mental health, preventive in-
tervention research, and ethics.
WORK ON THIS ARTICLE WAS SUPPORTED by National Institutes of Health
Research Grant R01-MH67893 funded by the National Institute of Mental
Health to Guillermo Bernal. Support was also received from the Institu-
tional Funds for Research from the Dean of Graduate Studies and Research
at the University of Puerto Rico, Rı´o Piedras.
WE ARE GRATEFUL to Amy Fontenot and Blanca Ortı´z-Torres for their
thoughtful comments on the manuscript of this article. An earlier version
of the article was presented at the 14th Robert Lee Sutherland Seminar,
Transforming Mental Health Services in Texas: Building Bridges Between
Cultural Competence and Evidence-Based Practice, Houston, Texas, No-
vember 2006, and at the Diversity Challenge: Race and Culture Intersec-
tions in Scientific Research and Mental Health Service Delivery for Chil-
dren, Adolescents, and Families, Boston, Massachusetts, October 2007.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Guill-
ermo Bernal, Institute for Psychological Research, 55 University Avenue,
Rivera Building, Suite 304, Rı´o Piedras, Puerto Rico 00925. E-mail:
Professional Psychology: Research and Practice © 2009 American Psychological Association
2009, Vol. 40, No. 4, 361–368 0735-7028/09/$12.00 DOI: 10.1037/a0016401
the systematic modification of an evidence-based treatment (EBT)
or intervention protocol to consider language, culture, and context
in such a way that it is compatible with the client’s cultural
patterns, meanings, and values. Adaptations that are well docu-
mented, systematic, and tested can advance research and inform
practice. EBTs represent an important advancement for the field in
terms of tools with established efficacy for specific treatments and
for specific disorders. An evidence-based cultural adaptation has
the potential to provide a methodology to modify treatments in a
systematic manner so that the culture and context of diverse groups
are considered. For example, Hwang (2009) and Nicolas, Arntz,
Hirsch, and Schmiedigen (2009) provided examples of culturally
adapted treatment interventions for Chinese Americans and Hai-
tian American adolescents that are systematic and culturally con-
sistent with each group. In both cases, the authors described their
procedures for cultural adaptation and collaboration with commu-
nity members. More research documenting processes like these
will further inform research and practice and increase the value
and likelihood of replication with other ECGs.
As currently conceptualized, cultural adaptations are tied to
treatments (e.g., Bernal, Bonilla, & Bellido, 1995), whereas cul-
tural competence is tied to specific provider practices (American
Psychological Association [APA], 2003; D. W. Sue & Sue, 2008).
This marriage of science and practice is consistent with the most
current report from the APA (2006), which calls for the use of an
evidence-based psychological practice (EBPP). This report, and
the values espoused within it, represents a natural and welcomed
growth in the movement toward integrating empiricism and psy-
chological practice. The work on which it is built now spans
almost two decades and was first crystallized with the report on
empirically validated treatments (Task Force, 1995). The empiri-
cally validated treatment label was quickly shed in favor of a more
“felicitous” label, empirically supported treatments (Chambless et
al., 1996). The EBT label (Levant & Hasan, 2008) is also used
interchangeably with empirically validated treatment and empiri-
cally supported treatment. The initial APA Task Force was focused
on identifying specific treatments (e.g., cognitive– behavioral ther-
apy) that worked for specific problems (e.g., enuresis), whereas the
movement toward evidence-based practice (or EBPP) is focused
on the treatments, the providers, and the clients or patients. In this
article, we focus on the rationale for and the efforts to make
specific treatments available to ethnocultural youths (also see
Nicolas, Arntz, Hirsch, & Schmiedigen, 2009) and their families;
as such, we use the label EBT throughout.
Heeding the EBPP Call:
Considering Culture in Specific Interventions
The field has conceptualized the need to take culture and context
into consideration (APA, 2006) in competent psychological prac-
tice, including specific treatments. Even before its EBPP publica-
tion, APA (2003) had approved multicultural guidelines on edu-
cation, training, practice, and organizational change, focusing on
the importance of integrating cultural context into all areas of
psychological practice. In addition, experts have acknowledged the
fit of EBPP with cultural competence (Whaley & Davis, 2007).
Many voices have historically contributed to making culture vis-
ible as an important variable for consideration in practice and
applied research (Kluckhorn & Strodtbeck, 1961; McGoldrick,
Pearce, & Giordano, 1982; Pedersen & Marsella, 1982; Rogler,
Malgady, Costantino, & Blumenthal, 1987; D. Sue & Sue, 1987).
Indeed, more than 4 decades ago, Gordon Paul (1967) pushed
researchers to move from asking “What treatments work?” to
asking “What treatment, by whom, is most effective for this indi-
vidual, with that specific problem, and under which set of circum-
stances?” (p. 111).
There is considerable evidence that culture and context influ-
ence almost every aspect of the diagnostic and treatment process
(Alegrı´a & McGuire, 2003; Canino & Alegrı´a, 2008; Comas-Dı´az,
2006). The more problematic and less often asked questions are
“How do we know when culture has been considered in a treat-
ment protocol?” and “What does that look like?” It is not surpris-
ing that authors have called for more flexibility with EBTs within
a framework of fidelity (Kendall & Beidas, 2007) so that adapta-
tions may be made. Others have called for systematic adaptations
to manuals and protocols such that culture, language, and socio-
economic contexts are explicitly considered (Hall, 2001; D. W.
Sue, Bingham, Porche-Burke, & Va´squez, 1999; Trimble & Mo-
hatt, 2002). However, there is still debate about whether and how
to adapt specific treatments for ethnocultural youths. We next
review the adaptation debates, followed by an assessment of the
current state of the science on how to adapt. Finally, we present
emerging evidence that adaptation is a fruitful enterprise.
Toward Cultural Adaptations of EBTs:
Cultural Compatibility and Universalistic Hypotheses
The interest in adaptation represents a middle ground to argu-
ments that range from recommendations to develop entirely new
treatments (Comas-Dı´az, 2006) to testing treatments as they are
across ECGs before engaging in the labor-intensive task of adap-
tation (Elliot & Mihalic, 2004). The extremes are most clearly
embodied in arguments for cultural compatibility of treatments and
the universalistic hypothesis. Tharp (1991) was one of the first
scholars to formulate the cultural compatibility hypothesis in psy-
chotherapy research by asserting that a “treatment is more effec-
tive when compatible with client culture patterns” (p. 802). The
null version of this hypothesis is that treatment should follow the
same set of procedures for all ECGs, that is, the universalistic view
(Tharp, 1991). The assumption is that both theoretical and proce-
dural models, as well as the mediators and change mechanisms, are
Proponents of culturally derived (new treatments) or culturally
adapted (adapted existing treatments; see Hwang, 2009, and Nico-
las et al., 2009) have presented a variety of arguments for their
position, including cultural sensitivity, ecological validity, and the
preponderance of evidence. Inherent in these positions is the
notion that people’s subjectivity and their culture are important
aspects of treatment. Hall (2001) defined culturally sensitive treat-
ments as involving “the tailoring of psychotherapy to specific
cultural contexts” (p. 502). He also noted that common constructs
that included interdependence, spirituality, and discrimination
emerged from the literature and may serve as a resource in adapt-
ing treatments to ECGs. The notion of dynamic sizing was pro-
posed by S. Sue (1998) in reference to the challenge of working
with cultural values without stereotyping, that is, knowing when to
focus on the individual and when to generalize across cultural
groups given that culture is a dynamic process. For a recent
NEZ-CHAFEY, AND DOMENECH RODRI
summary of these arguments, see Bernal and Jime´nez-Chafey
(2008). The universalistic hypothesis is further challenged by
citing threats to ecological validity and by the evidentiary argu-
The ecological validity argument posits that it is necessary to
increase the congruence between the experience of the client’s
ethnocultural world and the properties of a particular psychother-
apy as assumed by the therapist. In other words, all methods to
increase the congruence between the client’s cultural experience
and the properties of the therapy assumed by the clinician are
instances of cultural sensitivity (Bernal et al., 1995). Because most
research supporting EBTs has been conducted with White, middle-
class patients, the external validity of these treatments is unknown;
they may not generalize to other groups. A specific instance of
ecological validity is the notion of social validity when there is
evidence that some racial and ethnic groups respond poorly to EBT
approaches (Lau, 2006). For example, the acceptability and via-
bility of an intervention in community settings can affect the
engagement and attrition rate of participants in treatment. Thus,
poor response to treatment may be related to poor ecological and
social validity. The two adaptation models that Hwang (2009) and
Nicolas et al. (2009) have outlined provide further evidence of the
utility of inclusion in the community in which the intervention and
treatment take place. Their models also address a gap in the
literature by describing the process by which their adaptation, in
collaboration with community, occurs.
The evidentiary argument is based on a wealth of literature on
the consideration of culture, race, and ethnicity (Bernal et al.,
1995; Canino & Alegrı´a, 2008; Hall, 2001; Miranda et al., 2005;
Trimble & Mohatt, 2002; Sue, 1998). More specifically, there is
growing evidence of the need to adapt EBTs for specific ECGs in
terms of service use, treatment preferences, and beliefs about
health (Cauce et al., 2002), which points to the need to culturally
adapt treatment strategies (Bernal & Scharro´n-del-Rı´o, 2001). In
fact, there may be important differences in the relationship be-
tween the symptom constellation and a disorder for particular
ECGs (Alegrı´a & McGuire, 2003), and ethnic match between
patient and provider has been linked to positive outcomes (S. Sue,
1998). In a meta-analytic review of culturally adapted mental
health interventions (Griner & Smith, 2006), there was strong
support in favor of the culturally adapted interventions; effect sizes
(d ⫽ 0.45) suggested a moderately strong benefit of culturally
adapted interventions. These studies provide support for the cul-
tural compatibility hypothesis.
The arguments for cultural adaptation have been criticized on
the basis of feasibility. Because the cultural adaptation field is
relatively new, researchers testing treatments with a variety of
ECGs have engaged in cultural adaptation field tests and efficacy
trials. The argument presented is that gathering a critical mass of
evidence for the use of adapted treatments for ECGs via these trials
is impractical. Conducting efficacy tests by ethnicity by race by
treatment for all ECGs would be a very large undertaking, and
there are no resources for such studies. As an example, Kazdin
(2000) considered Paul’s (1967) question of what works with
whom as practically unanswerable because the number of avail-
able treatments by disorders “would require more than 100,000
studies” (p. 830) without even considering clients’ developmental
stage or comorbidity, among a host of other factors. In sum, the
approach is viewed as “crassly empirical” and simply not feasible.
Also, there are conceptual and empirical problems with the cate-
gories of race and ethnicity (Miranda et al., 2003). In this case, the
universalistic hypothesis is by default indirectly supported because
of the proposed lack of feasibility of conducting studies to ade-
quately answer the question of what works for whom. Although
the arguments against a particular methodological approach—
conducting intervention trials with all ECGs for all treatments of
all disorders— on the grounds of feasibility are strong, it is impor-
tant to note that the argument is bound by the current state of the
science. It is critical not to confuse the need for methodological
and conceptual advances in adapting treatments for ECGs with a
lack of need for cultural adaptation. From a research perspective,
carrying out cultural adaptations in the context of treatment out-
come studies presents unique opportunities to advance knowledge
of how psychotherapy works. Conducting clinical trials with spe-
cific ECGs offers the possibility of testing basic assumptions
regarding which mediators may be at work with a particular group,
as well as tests of the external validity of treatments. For example,
studies focused on specific ECGs could serve to confirm or dis-
confirm the universalistic hypothesis. Similarly, if specific medi-
ators are found to predict an outcome in one group but not in
another, the cultural compatibility hypothesis would be supported.
Two articles in this special section add to the literature in this area
by providing specific examples of the cultural adaptation process
for Chinese Americans (Hwang, 2009) and Haitian adolescents
(Nicolas et al., 2009). These studies have demonstrated that cul-
tural adaptation with specific ECGs can be useful in determining
what works for whom. To paraphrase Stanley Sue (1999), ethnic
science is good science. In addition, all clinicians have an ethical
responsibility to consider the diverse cultural background of their
clients in therapy. Trimble and Mohatt (2002) proposed that psy-
chotherapists have an ethical responsibility to offer the best pos-
sible treatment by taking into account the values, culture, and
context of their patients.
In addition to these aspirational and perhaps abstract reasons to
investigate the utility of cultural adaptations, there are practical
matters that make attending to adaptations relevant for many
psychologists. Some agencies (e.g., the Substance Abuse and
Mental Health Services Administration and the Centers for Dis-
ease Control and Prevention) now require documentation on the
use of EBTs. This places clinicians and administrators in the
unenviable position of having to use EBTs with populations for
whom they were not developed. This could result in the use of
interventions that are ineffective, or even harmful to ethnic minor-
ity patients. In addition to the concern about patient outcomes,
poor treatment response can also have a powerful effect on the
treating clinician, leading to a loss of confidence in EBTs or even
evidence-based psychological practice in general. The current state
of the science in the area of adaptations is, as with many emergent
specializations, lopsided. There are multiple conceptual models
that are developed at various degrees of complexity. There are
fewer instances of empirical research using existing models of
adaptation. However, work is certainly underway. We review the
model and associated empirical support for its use next.
Research on Cultural Adaptation of Psychotherapy
Several years ago, Bernal and Scharro´n-del-Rı´o (2001) called
for an integration of approaches to treatment research with ethnic
CULTURAL ADAPTATION OF EBT
minorities. They proposed an integration of hypothesis-testing and
discovery-oriented research to provide a broader, more inclusive,
detailed view of the psychotherapy process with specific ethnic
groups that could provide valuable information to guide adapta-
tions. Since then, increasing numbers of studies on cultural adap-
tations of psychotherapy have emerged in the literature (see
Hwang, 2009, and Nicolas et al., 2009), including two recent reviews
of culturally adapted treatment for ethnic minorities (Griner & Smith,
2006; Huey & Polo, 2008).
A meta-analysis of 76 culturally adapted mental health inter-
ventions conducted by Griner and Smith (2006) revealed a wide
range in types of cultural adaptations reported. Most studies (84%)
involved specifically including cultural values and concepts in the
intervention; 61% matched clients to therapists on ethnicity and
74% matched clients to therapists on native language; and 17%
provided cultural sensitivity training for professional staff. Fewer
efforts were reported in involving the community to improve
engagement and retention, with 38% of the studies including
collaboration or consultation with individuals familiar with the
culture, 29% providing outreach efforts to recruit underserved
clients, and 24% providing extra services to remove barriers for
attendance. Although this meta-analysis showed a moderately
strong benefit of culturally adapted interventions (d ⫽ 0.45), many
of the studies included did not explicitly describe the cultural
adaptation process used, and others have not been published (i.e.,
dissertations) so they are not easily accessible to the public for use
in guiding cultural adaptations.
Huey and Polo’s (2008) review focused specifically on EBTs
for ethnic minority youth, and the authors concluded that although
there are no well-established treatments for ethnic minority youth,
there are probably efficacious or possibly efficacious treatments
for minority youth with attention deficit disorder, depression,
conduct problems, substance abuse problems, and trauma-related
syndromes. These findings are consistent with an analysis of the
efficacy of mental health interventions with youth (Miranda et al.,
2003) that found that the best available evidence suggests that
some EBTs for depression, anxiety, attention deficit/hyperactivity
disorder, and conduct disorders are effective for African American
and Latino youth as well as for European American youth. Nicolas
et al. (2009) have extended our research evidence to include
Haitian American adolescents’ use of the culturally adapted Ado-
lescent Coping With Depression Course (ACDC). Although their
study is still in process, early progress indicates that cultural
adaptation of the ACDC has promising results for this population.
Huey and Polo’s (2008) meta-analysis (n ⫽ 25) revealed overall
treatment effects of medium magnitude (d ⫽ 0.44), which suggests
that 67% of treated ethnic minority youth were better off posttreat-
ment than the average control youth. Of these, 13 randomized
controlled trials evaluated ethnicity as a treatment moderator, yet
none found ethnicity to moderate treatment outcome. However,
Huey and Polo (2008) pointed out significant limitations to most of
these studies, such as low statistical power, small sample size, and
poor representation of less acculturated youth. They also brought
up the important issue of these studies’ cultural responsiveness;
although many included culture-responsive elements, many failed
to provide detailed descriptions of these elements. Of the studies,
only 14 could be defined as culture responsive using exceedingly
generous criteria for designating an intervention as responsive
(e.g., any identified characteristic of the treatment that suggested
compatibility with ECG), and none directly tested for these effects.
Griner and Smith’s (2006) and Huey and Polo’s (2008) meta-
analyses highlight two important findings: Cultural adaptations
seem to work in delivering treatments to ECGs, but much infor-
mation is still needed to understand what they are and how they
work. Although adaptation models exist, they have been published
relatively recently. The first published model was the Bernal et al.
(1995) model, followed by Leong’s (1996) cultural accommoda-
tion model. The next known published model followed almost 10
years later (Domenech Rodrı´guez & Wieling, 2004). Several more
adaptation models have been presented since. It is likely that these
models were not in wide use while the research that populated the
Griner and Smith and Huey and Polo meta-analyses was being
conducted. What follows is a review of existing models and
associated findings to support (or not) their use.
Frameworks for Culturally Adapting Psychotherapy
and Associated Findings
Recognizing the importance of using a guide or framework in
the adaptation process to assist replication and dissemination,
several researchers have developed specific models that provide a
systematic way to carry out and document adaptations that can be
useful for planning, replication, dissemination, and translation.
Studies using these frameworks to culturally adapt EBTs such as
cognitive– behavioral therapy (CBT) and parent training are be-
ginning to emerge in different research phases from process and
pilot studies to clinical controlled trials.
The first known framework proposed in the literature is the
ecological validity model (Bernal et al., 1995). This model, which
was originally conceptualized for Latino populations, consists of
eight dimensions of interventions (language, persons, metaphors,
content, concepts, goals, methods, and context) that can serve as a
guide for developing culturally sensitive treatments and adapting
existing psychotherapies to specific minority groups. Using this
model to adapt CBT and interpersonal therapy, Rossello´ and
Bernal (1999; Rossello´, Bernal, & Rivera, 2008) conducted two
randomized clinical controlled trials to examine the efficacy of
these treatments for Puerto Rican adolescents with depression.
Two examples of cultural adaptations made using the eight ele-
ments of the ecological validity model were (a) content—focus on
values of familismo and respeto while intervening with adoles-
cents—and (b) methods— encouragement of parent participation,
addressing balance among interdependence, dependence, and in-
dependence for the adolescent in therapy. In the first randomized
clinical controlled trial, 82% of adolescents in interpersonal ther-
apy and 59% in CBT were within the functional range after
treatment (Rossello´ & Bernal, 1999). In the second randomized
clinical controlled trial using variations in group and individual
format for CBT and interpersonal therapy, both group and indi-
vidual formats of CBT and interpersonal therapy produced positive
outcomes (Rossello´ et al., 2008).
The ecological validity model has also been used in research to
adapt parent– child interaction therapy with Puerto Rican children
and families (Matos, Torres, Santiago, Jurado, & Rodrı´guez,
2006). In this pilot work with nine families, the authors found that
the culturally adapted parent–child interaction therapy was accept-
able to parents and practitioners alike. In addition to treatment
NEZ-CHAFEY, AND DOMENECH RODRI
acceptability, Matos et al. (2006) reported high parental levels of
satisfaction with the intervention, reduced parental stress, and
improved parenting practices. They also recorded significant re-
ductions in child externalizing behaviors.
Domenech Rodrı´guez and Wieling (2004) expanded on the
ecological validity model to incorporate the process into a cultural
adaptation process model consisting of three general phases and 10
specific target areas. During the initial phase, the change agent
(researcher) and a community opinion leader collaborate to find a
balance between community needs and scientific integrity. In
Phase 2, evaluation measures are selected and adapted in a process
parallel to the adaptation of the intervention. The final phase
consists of integrating the observations and data gathered in Phase
2 into a new packaged intervention. Each phase consists of an
ongoing process of evaluation, revision, and reinvention.
Using the cultural adaptation process model, Domenech Rodrı´-
guez (2008) culturally adapted a parent management training–
Oregon model intervention for Mexican American families with
children who exhibit behavior problems (N ⫽ 87). By using data
collected from focus groups carried out with Mexican American
families, she culturally adapted the intervention along the eight
dimensions of the ecological validity model. For example, in terms
of language and metaphors, the adapted version uses idiomatic
expressions and dichos (popular sayings) to present educational
material. In relation to content and the definition of therapeutic
goals, she conceptualized and encouraged respeto and buena edu-
cacio´n (important cultural values for Latinos) as goals of the
intervention and reframed skills and limit setting as a means to
these goals. Taking into account the sociocultural context, the
intervention addresses some challenges that these families face,
such as lack of modeling from their own parents, fear of Child
Protective Services, parents’ low level of education and long work
hours, and gender roles within the culture by delivering the inter-
vention in a flexible format. Preliminary findings have shown good
retention of parents in the intervention and steeper improvements
in child outcomes in the treatment group than in the control group
(Domenech Rodrı´guez, 2008). Most recently, Nicolas et al. (2009)
used the ecological validity model as their foundation in culturally
adapting the ACDC with Haitian adolescents. As stated previ-
ously, early results of their study appear promising and consistent
with the results found in the Puerto Rican adolescent population.
In addition, Hwang (2006) proposed a psychotherapy adaptation
and modification framework specifically for Asian American im-
migrants that can also serve as a model that could be expanded to
adapt therapies for other ethnic groups. The psychotherapy adap-
tation and modification framework consists of six domains (dy-
namic issues and cultural complexities, orientation, cultural be-
liefs, client–therapist relationship, cultural differences in
expression and communication, and cultural issues of salience) and
25 therapeutic principles across these six domains. For a more
detailed description, see Hwang (2009).
Using this model, Hwang, Wood, Lin, and Cheung (2006)
reported a case study in which they used a culturally adapted CBT
to successfully treat school phobia in a 12-year-old Chinese Amer-
ican boy who experienced “drop attacks” when confronted with
school situations. Some of the principles of the psychotherapy
adaptation and modification framework for cultural adaptations
seen in this case example are establishing a goal for treatment that
the family values as well as focusing on factors that would moti-
vate the parents to take appropriate action on the basis of their
cultural beliefs; adapting therapy to accommodate patients’ lack of
comfort in talking about their feelings with therapists, which many
Chinese clients may feel; and becoming aware of the shame and
stigma associated with mental illness. Because somatic symptoms
are a less stigmatizing and more culturally appropriate expression
of anxiety in Chinese culture and serve as an escape behavior when
confronted with certain stressors (i.e., teasing), psychoeducational
information was presented in the context of physical symptoms
using a cultural bridging technique to link Asian cartoon culture
with Chinese culture and the connection between emotions and
somatic experiences. Most recently, Hwang (2009) proposed a
community-based developmental approach, the formative method
for adapting psychotherapy model, to be used in collaboration with
the psychotherapy adaptation and modification framework. The
formative method for adapting psychotherapy is a bottom-up ap-
proach that involves collaborating with consumers to generate and
support ideas for therapy adaptation and involves five phases that
target developing, testing, and reformulating therapy modifica-
tions. See Hwang (2009) for more details because the initial phases
of this model are also very promising for the enhancement and
replication of cultural adaptation models with other cultural
These models and the associated research findings suggest that
cultural adaptations have promise for the delivery of EBTs to
ECGs. That varied models seem to have utility is likely the
combination of commonalities across models (e.g., consideration
of clients’ cultural values) and the degree of flexibility with which
EBTs can be adapted for use with various ECGs. There are other
models presented in the literature for which findings regarding
their application have not been disseminated: Barrera and
Gonza´lez-Castro’s (2006) heuristic framework, Lau’s (2006) data-
driven adaptation, and Leong’s (1996) cultural accommodation
model. However, this work may be forthcoming.
The practice and research of psychological interventions have
undergone tremendous changes in the past two decades. These
changes are mostly ones of focus, meaning that leaders in the field
suggested a more central placement of empirically based psycho-
logical practice, including rigorous attention to interventions and
their associated evidence for use. This shift in perspective is
consistent with the predominant model of scientist–practitioner
training in psychology. However, until the publication of APA’s
(2006) EBPP report, the movement toward greater integration of
science in the practice of psychology had not been properly inte-
grated with the equally visible movement toward consideration of
culture and context in all areas of psychological practice (APA,
2003). This disconnect placed those clients—notably people from
ECGs—not represented in EBT research at risk for receiving
psychological services that were not adequate or appropriate or
that could possibly be harmful. The movement to use models of
cultural adaptation to adapt EBT provides a promising avenue to
bridge the gap between EBT and cultural competence.
The literature on the efficacy of treatments with ethnic minor-
ities is increasing and demonstrates some positive outcomes for
both EBTs and culturally adapted treatments. However, the wide
range of elements that are considered to be cultural adaptations in
CULTURAL ADAPTATION OF EBT
these studies (i.e., linguistic translations, patient–therapist match,
and community involvement), combined with the lack of consis-
tency in describing the process of culturally adapting an interven-
tion in a systematic way, makes it difficult to draw conclusions
about their efficacy with ECGs. Early attempts to adapt and test
adaptations have yielded promising results at the level of recruit-
ment, retention, and outcomes for ethnocultural youths. Undeni-
ably, much work remains to be done in answering basic questions;
confirming and extending existing findings, many of which are
pilot work; and testing untested models.
Basic questions regarding how much adaptation is needed, and
when should the adaptations occur can be answered with research
projects that engage in cultural adaptation efforts in very distinct
ECGs with varied clinical presentations. This is not to suggest an
exhaustive list of treatment trials but rather a strategic selection of
trials. If similar adaptation efforts yield similar benefits in, for
example, African American youths diagnosed with obsessive–
compulsive disorder and Asian American youths with conduct
disorder, then the cultural adaptation models might meet with
some degree of support for a broad application. The consider-
ation of the boundaries between an adapted intervention and the
original propositional model should be examined (Bernal &
Jime´nez-Chafey, 2008; Gonza´lez-Castro, Barrera, & Martı´nez,
2004). Did the adaptation change the proposed core components
and procedures to such an extent that it has become a different
Existing findings need to be confirmed with replication trials, as
is our scientific tradition. The replications would take place with
similar and varied ECGs. In further extending the work with
careful attention and documentation of adaptation efforts, these
findings can provide important information about broadly tailoring
interventions. For example, it is likely that cultural adaptations
made for language can also serve to make treatments more accept-
able to low-income White American clients. It is even more likely
that these adaptations have already been taking place but have not
been systematically documented or implemented. Additionally,
researchers directing intervention trials that are not focused on
cultural adaptation can make a contribution by recruiting diverse
samples and carefully reporting race and ethnicity data in their
disseminated findings to provide a source of information about the
efficacy or effectiveness of nonadapted treatments. This last rec-
ommendation may seem antiquated; however, a recent review of
funded research (379 National Institute of Mental Health clinical
trials) between 1995 and 2004 found that fewer than half of the
studies provided basic information on race and ethnicity and that
all ethnic groups except Whites and African Americans were
underrepresented (Mak, Law, Alviderez, & Pe´rez-Stable, 2007).
Finally, some adaptation models remain untested. For example,
Lau (2006) offered a middle ground between the universalistic and
the cultural compatibility hypotheses by proposing the use of data
to decide whether and when an adaptation is warranted. She
proposed a data-driven approach that begins with an analysis of
what cultural adaptations are warranted for a particular ECG. To
ensure compatibility with the needs of the target community while
ensuring fidelity to the EBT model, Lau (2006) proposed dual
approaches to a directed treatment adaptation in which the first
arm of the adaptation involves contextualizing content so that the
adapted intervention addresses the distinctive contextual factors
related to the presenting problem in the community and the second
arm involves enhancing engagement in EBT strategies with low
social validity. Barrera and Gonza´lez-Castro (2006) built on Lau’s
(2006) work and proposed a heuristic framework for determining
when EBTs might merit adaptation. They proposed a tripartite
framework for research that compares two or more subcultural
groups with subcomponents to evaluate the equivalence of engage-
ment, of action theory (ability of treatments to change mediating
variables), and of conceptual theory (relations between mediators
and outcomes). Differences observed in each component could
identify aspects of EBT content and implementing procedures that
might require adaptation.
In addition to extending existing work by testing other cultural
adaptation models, researchers might consider application to in-
ternational contexts. Bauermeister, So, Jensen, Krispin, and El Din
(2006) of the Integrated Services Program Task Force have de-
scribed the process of developing and adapting EBT manuals for
externalizing and internalizing disorders in children and adoles-
cents at four different sites (Egypt, Lebanon, Israel, and Brazil).
The amount and extent of adaptations needed at each site differed
significantly and in response to the unique needs of each cultural
group. Lessons learned in international applications can also in-
form local work.
It is important to recognize that the work cited here is tied to
specific adaptation models. There have been many more efforts to
culturally adapt interventions and deliver them to ECGs for which
no clear cultural adaptation model was used (e.g., Cardemil, Kim,
Pinedo, & Miller, 2005) or for which adaptations are reported to be
specific but a model has not been published (e.g., Huey & Pan,
2006). This is likely a reflection of the development of the cultural
adaptation field. There is a growing consensus on basic steps and
ways of approaching the process and content of cultural adapta-
tions that serve as an important methodological resource for the
field. Investigators should report all procedures in cultural adap-
tation (e.g., language in which the intervention was delivered,
ethnicity and race of the therapists, and translation procedures, if
any). In this way, future meta-analytic studies can use robust
criteria for defining cultural adaptation, and sound conclusions
may be drawn. Additionally, work to check on the implementation
of adaptations (akin to fidelity checks) may also be of use as
culturally adapted interventions are disseminated broadly.
Cultural adaptation is a valuable resource for investigators and
clinicians working with diverse populations. In addition, the work
on cultural adaptations serves as an important bridge between the
literature on cultural competence, cultural sensitivity, and, more
recently, multiculturalism and the EBT literature. Cultural adap-
tations may make it possible to go beyond the one-size-fits-all
approach and move closer to the ideal of providing effective
psychotherapies for all individuals, contextualized in terms of
cultural values, language, socioeconomic status, gender, and pref-
Alegrı´a, M., & McGuire, T. (2003). Rethinking a universal framework in
the psychiatric symptom– disorder relationship. Journal of Health and
Social Behavior, 44, 257–274.
American Psychological Association. (2003). Guidelines on multicultural
education, training, research, practice, and organizational change for
psychologists. American Psychologist, 58, 377– 402.
NEZ-CHAFEY, AND DOMENECH RODRI
American Psychological Association Task Force on Evidence-Based Prac-
tice. (2006). Evidence-based practice in psychology. American Psychol-
ogist, 61, 271–285.
Barrera, M., & Gonza´lez-Castro, F. (2006). A heuristic framework for the
cultural adaptation of interventions. Clinical Psychology: Science and
Practice, 13, 311–316.
Bauermeister, J., So, C. Y. C., Jensen, P., Krispin, O., & El Din, A. S.
(2006). Development of adaptable and flexible treatment manuals for
externalizing and internalizing disorders in children and adolescents.
Revista Brasileira Psiquiatria, 28, 67–71.
Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and
cultural sensitivity for outcome research: Issues for cultural adaptation
and development of psychosocial treatments with Hispanics. Journal of
Abnormal Child Psychology, 23, 67– 82.
Bernal, G., & Jime´nez-Chafey, M. I. (2008). Cultural adaptation of psy-
chotherapy for ethnic-minority youth: Beyond one-size-fits-all. Child
and Family Policy and Practice Review, 4, 3– 6.
Bernal, G., & Scharro´n del Rı´o, M. (2001). Are empirically supported
treatments valid for ethnic minorities? Toward an alternative approach
for treatment research. Cultural Diversity and Ethnic Minority Psychol-
ogy, 7, 328 –342.
Canino, G., & Alegrı´a, M. (2008). Psychiatric diagnosis—Is it universal or
relative to culture? Journal of Child Psychology and Psychiatry, 49,
Cardemil, E. V., Kim, S., Pinedo, T. M., & Miller, I. W. (2005). Devel-
oping a culturally appropriate depression prevention program: The Fam-
ily Coping Skills Program. Cultural Diversity and Ethnic Minority
Psychology, 11, 99 –112.
Cauce, A. M., Domenech Rodrı´guez, M., Paradise, M., Cochran, B. N.,
Shea, J. M., Srebnik, D., et al. (2002). Cultural and contextual influences
in mental health help seeking: A focus on ethnic minority youth. Journal
of Consulting and Clinical Psychology, 70, 44 –55.
Chambless, D. L., Sanderson, W. C., Shoham, V., Johnson, S. B., Pope,
K. S., Crits-Christoph, P., et al. (1996). An update on empirically
validated therapies. Clinical Psychologist, 49, 5–18.
Comas-Dı´az, L. (2006). Latino healing: The integration of ethnic psychol-
ogy into psychotherapy. Psychotherapy: Theory, Research, Practice,
Training, 4, 436 – 453.
Domenech Rodrı´guez, M. M. (2008, December). Outcomes of a RCT of
PMTO for Spanish-speaking Latino parents: Behavioral observations of
parenting practices. Paper presented at the National Institute of Health
Summit: The Science of Eliminating Health Disparities, Washington
Domenech Rodrı´guez, M., & Weiling, E. (2004). Developing culturally
appropriate, evidence-based treatments for interventions with ethnic
minority populations. In M. Rastogin & E. Weiling (Eds.), Voices of
color: First person accounts of ethnic minority therapists (pp. 313–333).
Thousand Oaks, CA: Sage.
Elliot, D. S., & Mihalic, S. (2004). Issues in disseminating and replicating
effective prevention programs. Prevention Science, 5, 47–53.
Gonza´lez-Castro, F., Barrera, M., & Martı´nez, C. R. (2004). The cultural
adaptation of prevention interventions: Resolving tensions between fi-
delity and fit. Prevention Science, 5, 41– 45.
Griner, D., & Smith, T. B. (2006). Culturally adapted mental health
interventions: A meta-analytic review. Psychotherapy: Theory, Re-
search, Practice, Training, 43, 531–548.
Hall, G. C. N. (2001). Psychotherapy research with ethnic minorities:
Empirical, ethical, and conceptual issues. Journal of Consulting and
Clinical Psychology, 69, 502–510.
Huey, S. J., & Pan, D. (2006). Culture-responsive one-session treatment for
phobic Asian Americans: A pilot study. Psychotherapy: Theory, Re-
search, Practice, Training, 43, 549 –554.
Huey, S. J., & Polo, A. J. (2008). Evidence-based psychosocial treatments
for ethnic minority youth: A review and meta-analysis. Journal of
Clinical Child and Adolescent Psychology, 37, 262–301.
Hwang, W. (2006). The psychotherapy adaptation and modification frame-
work: Application to Asian Americans. American Psychologist, 61, 702–
Hwang, W. (2009). The formative method for adapting psychotherapy
(FMAP): A community-based developmental approach to culturally
adapting therapy. Professional Psychology: Research and Practice, 40,
Hwang, W., Wood, J. J., Lin, K., & Cheung, F. (2006). Cognitive-
behavioral therapy with Chinese Americans: Research, theory, and clin-
ical practice. Cognitive and Behavioral Practice, 13, 293–303.
Kazdin, A. E. (2000). Developing a research agenda for child and adoles-
cent psychotherapy. Archives of General Psychiatry, 57, 829 – 835.
Kendall, P. C., & Beidas, R. S. (2007). Smoothing the trail for dissemi-
nation of evidence-based practices for youth: Flexibility within fidelity.
Professional Psychology: Research and Practice, 38, 13–20.
Kluckhorn, F., & Strodtbeck, F. (1961). Variations in value orientations.
Evanston, IL: Row, Peterson.
Lau, A. S. (2006). Making the case for selective and directed cultural
adaptations of evidence-based treatments: Examples from parent train-
ing. Clinical Psychology: Science and Practice, 13, 295–310.
Leong, F. T. (1996). Toward an integrative model of cross-cultural counseling
and psychotherapy. Applied and Preventive Psychology, 5, 189 –209.
Levant, R. F., & Hasan, N. T. (2008). Evidence-based practice in psychol-
ogy. Professional Psychology: Research and Practice, 39, 658 – 662.
Mak, W. W., Law, R. W., Alviderez, J., & Pe´rez-Stable, E. J. (2007).
Gender and ethnic diversity in NIMH-funded clinical trials: Review of a
decade of published research. Administration Policy and Mental Health,
Matos, M., Torres, R., Santiago, R., Jurado, M., & Rodrı´guez, I. (2006).
Adaptation of parent-child interaction therapy for Puerto Rican families:
A preliminary study. Family Process, 45, 205–222.
McGoldrick, M., Pearce, J. K., & Giordano, J. (1982). Ethnicity and family
therapy. New York: Guilford Press.
Miranda, J., Bernal, G., Lau, A. S., Kohn, L., Hwang, W., & LaFromboise,
T. (2005). State of the science on psychosocial interventions for ethnic
minorities. Annual Review of Clinical Psychology, 1, 113–142.
Miranda, J., Duan, N., Sherbourne, C., Schoenbaum, M., Lagomasino, I.,
Jackson-Triche, M., et al. (2003). Improving care for minorities: Can
quality improvement interventions improve care and outcomes for de-
pressed minorities? Results of a randomized, controlled trial. Health
Services Research, 38, 613– 630.
Nicolas, G., Arntz, D. L., Hirsch, B., & Schmiedigen, A. (2009). Cultural
adaptation of a group treatment for Haitian American adolescents. Pro-
fessional Psychology: Research and Practice, 40, 378 –384.
Paul, G. (1967). Strategy of outcome research in psychotherapy. Journal of
Consulting Psychology, 31, 109 –118.
Pedersen, P. B., & Marsella, A. J. (1982). The ethical crisis for cross-
cultural counseling and therapy. Professional Psychology: Research and
Practice, 13, 492–500.
Rogler, L. H., Malgady, R. G., Costantino, G., & Blumenthal, R. (1987).
What do culturally sensitive mental health services mean? The case of
Hispanics. American Psychologist, 42, 565–570.
Rossello´, J., & Bernal, G. (1999). The efficacy of cognitive– behavioral and
interpersonal treatments for depression in Puerto Rican adolescents.
Journal of Consulting and Clinical Psychology, 67, 734 –745.
Rossello´, J., Bernal, G., & Rivera, C. (2008). Randomized trial of CBT and
IPT in individual and group format for depression in Puerto Rican
adolescents. Cultural Diversity and Ethnic Minority Psychology, 14,
Sue, D. W., Bingham, R. P., Porche-Burke, L., & Vasquez, M. (1999). The
diversification of psychology: A multicultural revolution. American
Psychologist, 54, 1061–1069.
CULTURAL ADAPTATION OF EBT
Sue, D., & Sue, S. (1987). Cultural factors in the clinical assessment of
Asian Americans. Journal of Consulting and Clinical Psychology, 55,
479 – 487.
Sue, D. W., & Sue, D. (2008). Counseling the culturally diverse: Theory
and practice (5th ed.). Hoboken, NJ: Wiley.
Sue, S. (1998). In search of cultural competence in psychotherapy and
counseling. American Psychologist, 53, 440 – 448.
Sue, S. (1999). Science, ethnicity, and bias: Where have we gone wrong?
American Psychologist, 54, 1070 –1077.
Sue, S. (2003). In defense of cultural competency in psychotherapy and
treatment. American Psychologist, 58, 964 –970.
Task Force on Promotion and Dissemination of Psychological Procedures.
(1995). Training in and dissemination of empirically validated treat-
ments: Report and recommendations. Clinical Psychologist, 48, 3–23.
Tharp, R. G. (1991). Cultural diversity and the treatment of children.
Journal of Consulting and Clinical Psychology, 59, 799 – 812.
Trimble, J. E., & Mohatt, G. V. (2002). Coda: The virtuous and responsible
researcher in another culture. In J. E. Trimble & C. B. Fisher (Eds.), The
handbook of ethical research with ethnocultural populations and com-
munities (pp. 325–334). Thousand Oaks, CA: Sage.
Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-
based practice in mental health services: A complementary perspective.
American Psychologist, 62, 563–574.
Received August 19, 2008
Accepted March 12, 2009 䡲
NEZ-CHAFEY, AND DOMENECH RODRI