Cultural Relevance within Full Service Partnerships

Lynne Marsenich, LCSW

January 2007

Full Service Partnership Training

Every person is in certain respects

a.Like all other people

b.Like some other people

c.Like no other person

(Kluckhorn & Murray, 1953)

Three Levels of Human Phenomena

• First, all human beings share universal characteristics

• Second, groups of us share cultural norms such as language and ways of socializing our children

• Third, each of us is unique

Framework for Culturally Appropriate Interventions

• Selection of therapeutic principles and techniques with (potentially) universal relevance

• Identification of culturally relevant intervention approaches

• Tailored to individuals

• Empirical evaluation of intervention outcomes

Steps for Identifying Effective AND Culturally Relevant Interventions

• Core components– Theory– Mechanisms of change

• Culturally responsive strategies– Use of culturally relevant images, metaphors and

stories– Acknowledges and addresses cultural values– Spirituality and Religion

• Willingness to inquire about, acknowledge and incorporate spiritual themes generated by clients

Effective and Culturally Relevant Interventions

• Culturally Responsive Strategies– Acculturation

• Creating a safe environment to discuss the stresses involved in navigating and adapting to a new culture

– Racism, prejudice and discrimination• Acknowledge the reality and traumatic impact of

such experiences

Effective and Culturally Relevant Interventions

• Must appreciate the heterogeneity within groups

• Dynamic sizing– Knowing when to generalize and be inclusive

and when to generalize and be exclusive when working with clients.

– Dynamic sizing avoids stereotypes while still appreciating the importance of culture

(Sue, 2006)

Increasing Access and Utilization

• Concrete barriers – generally imposed by economic limitations or current life circumstances

• Perceived – informed by an individuals culture, attitudes and previous experiences

Concrete Barriers

• Location of service deliver site

• Lack of transportation

• Lack of child care

• Single parent with care giving responsibilities for adults and children

• Having children with serious health problems

Perceived Barriers

• Stigma associated with help seeking

• Lack of social support – friends and/or family not supportive of treatment

• Previous experiences with help-seeking

• Feeling misunderstood or disrespected

• Doubts about the utility of treatment

• Cultural meaning of help seeking

Culturally Relevant and Effective Interventions

• Some EBP’s have been tested with diverse populations– Multisystemic Therapy– Parent Child Interaction Therapy– Incredible Years– Cognitive Behavioral Therapy– Interpersonal Psychotherapy for Depression– Trauma Focused CBT– Multi-Dimensional Family Therapy

Culturally Sensitive Interventions

• Facilitate accessibility of services

• Make use of methods that are acceptable and appropriate given the cultural values of the client

• Interventions must be further tailored to each individual client – appreciate the variability that exists within groups

(Munoz, 2005)

Incredible Years

• Intervention for young children (3-8) with disruptive behavior disorders

• Developed by Carolyn Webster-Stratton• Goals of treatment

– Decrease aggressive oppositional behavior– Strengthen children’s social competence and

self-regulation– Promote children’s academic competence,

school engagement and school readiness

IY-Intervention Methods

• Group – 10-14 parents• 12-14 weeks• Videotaped modeling• Role Play and rehearsal• Home assignments• Group support• Emphasis on therapeutic relationship

–”collaborative process”

IY – Fundamental Tenet

• Parents care about their children’s welfare and would prefer to behave in ways that facilitate their children’s development and success in school

IY – Core Components - Theory

• Social Learning Theory (Bandura, 1977)– Embodies principles of behavior change that

are potentially applicable across cultures– Emphasizes the principle of reciprocal

determinism – individuals both shape and are shaped by their environments

– Teaching adaptive coping strategies are at the heart of the theory

IY –Core Components-Mechanisms of Change

• Play to promote positive parent-child relationships

• Praise and incentives to promote social competence

• Effective limit setting to increase cooperation

• Ignore, distract, redirect and time out to decrease aggressive behavior

IY – Culturally Responsive Strategies

• Parents determine their own goals for themselves and their children– Each unique group of parents generates the

themes and principles that guide the discussions and exercises

– The role plays and practices come from the parent’s needs and issues

– The group process supports members different opinions and goals

Themes Commonly Expressed by Immigrant Parents

• Loss of control or power of parents in the home regarding child rearing– Parents are encouraged to try discipline

techniques that are compatible with their cultural identity and increase their confidence about parenting in a new culture

Common Themes • Parents feel they engage in a balancing act

between wanting their children to maintain their cultural identity while at the same time making the necessary adaptations so they can be successful in the United States– Parents are encouraged to read to children in their

own language– To continue their oral history by telling stories about

their childhoods and countries of origin– Strengthening their relationships with their children as

a means of strengthening their child’s bond to them and their culture

Common Themes

• Language and communication barriers make it difficult for parents to know how to interact with teachers and support their children’s academic success– Parents are helped to know how to

collaborate with teachers so they understand what is expected of their child

– Group leaders contact teachers to find ways of increasing two-way communication between home and school

Common Themes

• Family stress, poverty, long work hours and financial struggles– The IY groups alleviate as many of the practical

barriers to attendance as possible• Help with transportation• Offering the group at times families can come• Meals• Child Care• Practical support for school involvement• Letting parents decided how much time they can spend on

the home assignments

Respect for Families’ Culture, Individual Values and Goals

• Terminology and parenting concepts are defined using language that is culturally determined

• Program materials are translated• Models in the vignettes represent different

cultural groups• Groups leaders need to understand and value

parent’s culture• Focus groups prior to offering IY to an group of

parents from a different culture

Empirical Evaluation of Outcomes

• Incredible Years is a well-validated intervention

• Carolyn Webster Stratton has conducted 6 random assignment studies and there have been 4 independent replications

Multidimensional Family Therapy

• Family based intervention for substance-abusing adolescents and other problem behaviors

• Developed by Howard Liddle• Goals of treatment

– Decrease in substance use– Decreases in delinquent behavior– Improved school functioning (behavior and grades)– Improved parent-adolescent communication and

relationship

MDFT Intervention Methods• Community and home-based family therapy• Treatment is organized in phases and the full

course of treatment ranges between 16 and 25 sessions over four to six months

• There are 5 assessment and intervention modules– Individual– Peer– Family– School– Community

Theory

• Adolescent drug abuse is understood in terms of a network of influences– Individual– Family– Peer– Community

• Reductions in drug use and increase in prosocial behavior occur via multiple pathways, in differing contexts and through different mechanisms

• Changes in parent well-being and in parenting practices is key to change

Intervention by Domain

• Individual– Individual session focus on youth’s difficulties

in school, in family, legal problems and relationship problems

– Motivation is enhanced and skills are taught and practiced

Intervention by Domain

• Peer

• The youth’s peer network is accessed through the youth who is then helped to address the non-adaptive nature of relationships with drug-using and delinquent peers

Intervention by Domain

• Family– Family sessions, sessions with parents focus

on every day events in the family, particularly family relationships and their improvement

– The past is explored and addressed to the extent that it still creates family relationship problems

Intervention by Domain

• School– Therapists go to the school with parents and

youth, sometimes acting as mediator, advocate, or brokers to create new opportunities for the youth in the school or to create opportunities for the youth in a new or different school environment.

Intervention by Domain

• Community– Therapists work with families to be more

vigilant about the dangers existing or the resources available to them within their local community

Culturally Specific MDFT for African American Males

• Cultural theme engagement module– Assessment of and interventions within multiple

systems of the adolescent's life– An emphasis on facilitating active adolescent

involvement in treatment– The use of popular culture including music– Focused and systematic discussion of cultural themes

such as mistrust, anger/rage, alienation, respect/disrespect, spirituality, the journey from boyhood to manhood, racism, racial socialization, hopelessness

Culturally Specific Strategies

• Gaining access through music

• The journey from boyhood to manhood– Therapy becomes the context within which the

adolescent inventories his sills and preparedness for manhood

– Identifying and integrating male mentors is a critical component

– Opportunities to strengthen the adolescent’s attachments to family and community

Culturally Specific Strategies

• Therapist helps the adults in the adolescent’s life to incorporate the role of mentor or trainer into their parenting

• Youth of color can experience difficulty when they venture beyond the boundaries of their immediate environments. Therefore teens are helped to gain experience and develop competence in new environments– Tutoring– Job training programs

Culturally Specific Strategies

• Employing culturally specific strategies are successful at retaining families in treatment longer than in traditional outpatient and residential drug treatment programs

(Dakof, Rowe, Liddle, & Henderson, 2003)

Outcomes Achieved – Incredible Years

• Increase in positive parenting

• Less harsh discipline

• Decease in child behavior problems

• 2/3 of the children were functioning in the normal range socially and academically at a 3 year follow up

Evaluation of Outcomes with Diverse Populations

• Reid, Webster-Stratton and Beauchaine, 2001– Asian (Vietnamese), African American and

Latino parents– Parents reported decreased child behavior

problems at one year follow-up and increased parental confidence

– Parents rated the group discussion, group support and free child care as the most valuable aspects of the program

Independent Replications with Diverse Populations

• Rojas-Flores, 2001 – Latino Families

• Gross, 2002 – African American families with 2-3 year old children– Increase in positive parenting– Decrease in harsh discipline– Increase in child competence– Decrease in behavior problems