Culturally adapted CBT for Māori
Māori are the indigenous people of New Zealand and according to 2006 census data comprised 14.9% of New Zealand's population of over 4 million (Statistics New Zealand, 2006). Over the years subsequent to the European settlement of New Zealand in the late 1700s and early 1800s, Māori experienced considerable loss of land and autonomy (King, Reference King2003). It is postulated by a number of authors that contact with Europeans gave rise to a range of issues that have contributed to poor economic, social and health outcomes for the Māori population (e.g. Durie, Reference Durie2001; Walker, Reference Walker1990).
Māori are disproportionately represented in statistics that indicate that they experience poorer health outcomes in relation to non-Māori. The results of Te Rau Hinengaro (The New Zealand Mental Health Survey; Oakley-Browne et al. Reference Oakley-Browne, Wells, Scott, Kessler and Üstün2008) have given greater certainty to the postulated assertion that Māori experience a higher prevalence of common mental disorders than the rest of the New Zealand population. Specifically, Te Rau Hinengaro reported that Māori displayed a significantly higher prevalence of mood disorders, anxiety disorders, and substance use disorders compared to non-Māori. Mood disorders were extremely pervasive with 15.7% of Māori experiencing a major depressive episode at some point in their life and 24.3% of Māori experiencing ‘any mood disorder’ at some stage in their lives (Baxter et al. Reference Baxter, Kingi, Tapsell, Durie, Oakley Browne, Wells and Scott2006). These figures indicate that despite the allocation of government resource into the fields of health and education aimed at addressing this imbalance, inequities between Māori and non-Māori in the incidence of mental illness remain significant
Te Rau Hinengaro also reported on the low rate of health service utilization by Māori with mental illness. Most telling among the statistics pertaining to service utilization was the finding that of those Māori experiencing serious disorders only 52.1% had contact with the health sector (Baxter et al. Reference Baxter, Kingi, Tapsell, Durie, Oakley Browne, Wells and Scott2006). While the Te Rau Hinengaro study was not designed to explore causative explanations for the low rate of service utilization by Māori, the findings would certainly support the over-arching goal of this study to thread Māori values through a common psychological treatment approach to increase its appeal to Māori service users. Improved service utilization is one of the likely flow-on effects of improving the treatment experience for those Māori who do access mental health services.
The essence of New Zealand's founding document, the Treaty of Waitangi (first signed in 1840) as well as contemporary interpretations of the Treaty (e.g. Durie, Reference Durie and Kawharu1989; Kawharu, Reference Kawharu1989), allude to crown/government obligations to ensure equity in terms of access to health services and the experience of good health itself. Along with the results of Te Rau Hinengaro, there is strong justification for further research that has the potential to improve psychological service provision and improve mental health outcomes to and for Māori.
Māori ideologies and the inherently Western practice of clinical psychology diverge at a number of levels. Numerous authors have alluded to the philosophical tensions that exist between Māori ways of understanding and viewing the world and those of the psychological discipline (e.g. Abbott & Durie, Reference Abbott and Durie1987; Lawson-Te Aho, Reference Lawson-Te Aho1994; Paewai, Reference Paewai1997; Nathan, Reference Nathan1999). These authors have stressed the importance that the psychological profession in New Zealand must evolve to more adequately support the aspirations of the Māori population. Durie (Reference Durie2004) argued that when the conceptualizations about health held by a specific population are disregarded it can lead researchers and clinicians towards misleading diagnostic and treatment decisions. While Māori are as diverse as any other group, in order for Western approaches to psychology to be adapted and refined to improve their relevance to Māori clientele, it is important to consider some of the more common values and beliefs that underpin a Māori worldview. For some time there has been strong support for the development of a Māori specific psychology as a mechanism for (among other things) the promotion and betterment of Māori mental health (Levy, Reference Levy2007).
CBT has been extensively researched and a vast number of well-controlled studies have supported the efficacy of cognitive behavioural therapy (CBT) in the treatment of depression over a number of years (e.g. Blackburn et al. Reference Blackburn, Bishop, Glen, Whalley and Christie1981; Hersen et al. Reference Hersen, Himmelhoch, Thase and Bellack1984; Keller et al. Reference Keller, McCullough, Klein, Arnow, Dunner and Gelenberg2000; Dubicka, Reference Dubicka2008; Soroudi et al. Reference Soroudi, Perez, Gonzalez, Greer, Pollack, Otto and Safren2008). CBT has also been shown to be an effective intervention for depression across the lifespan with studies indicating successful outcomes with children and adolescents (Curry, Reference Curry2001), and the elderly (Koder et al. Reference Koder, Brodaty and Anstey1996). While the original CBT manual was developed to treat depression, the core principles of CBT have been adapted and successfully applied to a range of mental health issues including anxiety disorders (e.g. Dugas & Ladouceur, Reference Dugas and Ladouceur2000; Dugas et al. Reference Dugas, Ladouceur, Léger, Freeston, Langolis, Provencher and Boisvert2003; Pina et al. Reference Pina, Silverman, Fuentes, Kurtines and Weems2003; Manassis et al. Reference Manassis, Avery, Butalia and Mendlowitz2004; Wattar et al. Reference Wattar, Sorensen, Buemann, Birket-Smith, Salkovskis, Albertsen and Strange2005), personality disorders (e.g. Koerner & Linehan, Reference Koerner and Linehan2000; Pretzer & Beck, Reference Pretzer, Beck, Clarkin and Lenzenweger1996; Sunseri, Reference Sunseri2004), bipolar disorder (e.g. Schmitz et al. Reference Schmitz, Averill, Sayre, McCleary, Moeller and Swann2002; Jones, Reference Jones2004), and substance abuse (e.g. Linehan et al. Reference Linehan, Schmidt, Dimeff, Craft, Kanter and Comtois1999; Feeney et al. Reference Feeney, Young, Connor, Tucker and McPherson2002; Waldron & Kaminer, Reference Waldron and Kaminer2004; Zlotnick et al. Reference Zlotnick, Johnson and Najavits2009).
While a number of major studies have utilized clinical trials to investigate and validate CBT as a highly effective treatment for a range of mental disorders in a range of conditions, the majority of these studies have either not collected data related to ethnic identity, or lacked the statistical power to examine the response of ethnic minority groups to CBT due to the lack of minority representation in controlled trials (Miranda et al. Reference Miranda, Bernal, Lau, Kohn, Hwang and LaFromboise2005). Concerns were raised by the Surgeon General of the USA that despite the existence of a range of treatments for mental disorder, minority groups were largely omitted from efficacy studies (US Department of Health and Human Services, 2005). It has thus been suggested that predictions regarding treatment outcome should be more modest when applying ‘empirically supported therapies’ to non-Western populations (Westen & Bradley, Reference Westen and Bradley2005).
A rapidly growing body of literature has provided empirical support for the adaptation of CBT to make it a more relevant intervention for non-Western cultural groups (e.g. Bernal et al. Reference Bernal, Jiménez-Chafey and Domenech Rodríguez2009; Laliberté et al. Reference Laliberté, Nagel, Haswell, Bennett-Levy, Richards, Farrand, Christensen, Griffiths, Kavanagh, Klein, Lau, Proudfoot, Ritterband, White and Williams2010; Hinton et al. Reference Hinton, Hofmann, Rivera, Otto and Pollack2011; Bennett & Babbage, Reference Bennett and Babbage2014; Bennett-Levy et al. Reference Bennett-Levy, Wilson, Nelson, Stirling, Ryan, Rotumah, Budden and Beale2014). Adaptations to CBT have been recommended across a range of cultural contexts by a number of authors. These have included the incorporation of a spiritual dimension in CBT (e.g. Duarté-Vélez et al. Reference Duarté-Vélez, Bernal and Bonilla2010), the integration of collective cultural values (Rosselló et al. Reference Rosselló, Bernal and Rivera-Medina2012), adapted techniques for building a therapeutic alliance (e.g. Asnaani & Hofmann, Reference Asnaani and Hofmann2012), and an awareness of ideological differences (e.g. Hinton et al. Reference Hinton, Rivera, Hofmann, Barlow and Otto2012).
This piece of research evaluates what level of impact a culturally adapted cognitive behavioural therapy approach can have on Māori clients with depression. It sets out to ascertain whether a culturally adapted version of CBT can demonstrate comparable rates of effectiveness, to those reported in the international literature regarding CBT and depression.
Method
During the preparatory phases of this study, approaches were made to the management of Māori Mental Health Services. These services are tertiary-level mental health services that provide government-funded assessment and treatment for Māori experiencing moderate to severe Axis I mental disorders. Initial response to the proposal was positive: feedback was provided and guidance was given by the service leaders as to further consultation that would be necessary prior to approval being granted for participant recruitment to proceed. Additional consultation was conducted with local tribal bodies as well as consultation with relevant groups internal to local mental health services.
The original design of this study was revised at various stages in response to feedback received through the consultation outlined above. Significant among these changes was the decision to expand the inclusion criteria to include individuals with co-morbid psychiatric features. The feedback that emerged from the consultative process indicated that these criteria would be excessively restrictive given the secondary nature of care provided by Māori mental health services. It was suggested that few if any current clients of these services would meet more restrictive criteria. This change in the inclusion criteria was consistent with literature that has criticized the restrictive inclusion criteria employed by many clinical trials. Such restrictions raise questions regarding the practical validity of results given the typically complex nature of clinical populations (Westen & Bradley, Reference Westen and Bradley2005). Although this change introduced additional confounds and increased variation inherent in the treatment population it was deemed by the groups consulted with, that it would increase the practical applicability of the research.
Participants
To be eligible for this study individuals had to self-identify as Māori, be aged ≥18 years, and experience symptoms of depression as their primary presenting issue. Sixteen individuals of Māori descent participated in this study. The sample ranged in age from 19 to 57 years and included five males and 11 females. At the time of their recruitment into the study levels of depression in the sample as measured by the Beck Depression Inventory - II (BDI-II; Beck et al. Reference Beck, Steer and Brown1996) ranged from mild to severe. However the sole participant with a pre-treatment score in the mild range withdrew from the study after attending just two sessions. A range of co-morbid factors were identified by the respective care teams as present among the participants in this research. These included alcohol and substance abuse (n = 7), anxiety disorders (n = 6), personality disorders (n = 3), and prior diagnoses of bipolar II disorder (n = 2). However, all of the participants had been given a primary diagnosis of a major depressive episode. Table 1 provides more detailed demographic information pertaining to the 16 participants.
Table 1. Participant characteristics and clinical presentation at assessment
aAs measured by the Beck Depression Inventory – II.
Measures
Beck Depression Inventory – 2nd edition (BDI-II). The BDI-II is a 21-item self-report measure with each answer scored on a scale ranging from 0 to 3. It has excellent face validity and is in wide clinical use in New Zealand (Patchett-Anderson, Reference Patchett-Anderson1997). The cut-offs suggested by the authors to describe the severity of depression are: 0–13 minimal depression, 14–19 mild depression, 20–28 moderate depression, and 29–63 severe depression. The BDI-II has been shown to have a high 1-week test–retest reliability (Pearson's r = 0.93), as well as high internal consistency (α = 0.91) (Beck et al. Reference Beck, Steer and Brown1996).
Numerous studies into the effectiveness of CBT for depression have used its predecessor the BDI, to monitor treatment progress (e.g. Kohn et al. Reference Kohn, Oden, Muñoz, Robinson and Leavitt2002; Gelman et al. Reference Gelman, López and Foster2006; Okazaki & Tanaka-Matsumi, Reference Okazaki, Tanaka-Matsumi, Hays and Iwamasa2006). The BDI-II is a highly clinically valid assessment tool and is used by healthcare professionals and researchers in a variety of clinical settings . The BDI-II has also been found to be sensitive to changes in depression over time (Sprinkle et al. Reference Sprinkle, Lurie, Insko, Atkinson, Jones, Logan and Bissada2002) and is designed to be able to be completed on multiple occasions, making it a highly suitable measure for tracking progress throughout treatment.
A study investigating the psychometric properties of the BDI-II when used with African-American suicide attempters has also given support to the cross-cultural use of the BDI-II. The authors found it to be a ‘reliable and valid measure of depressive symptoms’ in this population reporting a Cronbach's alpha of 0.94 and moderate convergent validity (r = 0.66) with the Hamilton Depression Rating Scale (Joe et al. Reference Joe, Woolley, Brown, Ghahramanlou-Holloway and Beck2008).
Automatic Thought Questionnaire (ATQ). The ATQ was developed by Hollon & Kendall (Reference Hollon and Kendall1980) and was designed to measure the frequency that automatic negative thoughts associated with depression occurred. The ATQ consists of 30 items comprising a series of negative self-statements that respondents indicate how frequently they experience. It has been constructed and validated using male and female undergraduates as subjects. Split-half reliability coefficients have been recorded at 0.97 and coefficient alphas have been found to be 0.96 and it has also been found to show good criterion-related validity in discriminating between depressed and non-depressed respondents (Hollon & Kendall, Reference Hollon and Kendall1980).
Possible scores on the ATQ-30 range from 30 to 150. Hollon & Kendall (Reference Hollon and Kendall1980) report mean scores for depressed individuals on the ATQ-30 of 79.64 (s.d. = 22.29) and mean scores for non-depressed individuals of 48.57 (s.d. = 10.89).
The cognitive focus of the ATQ makes it a useful measure of the frequency of negative thinking among clients receiving CBT. The ATQ is widely used in CBT outcome research to measure the frequency of negative cognition (e.g. Griffiths et al. Reference Griffiths, Christensen, Jorm, Evans and Groves2004; Kaufman et al. Reference Kaufman, Rohde, Seeley, Clarke and Stice2005; Allart-Van Dam, et al. Reference Allart-van Dam, Hosman, Hoogduin and Schaap2007).
Procedure
A 12-session adapted cognitive behavioural treatment protocol for Māori with depression was developed for the purposes of this study. The development of the protocol and the nature of the adaptations are described in detail elsewhere (Bennett, Reference Bennett2009) and is the subject of a manuscript currently being prepared for submission. However, in brief, the manual was developed in accordance with culturally relevant literature, CBT literature and in consultation with an advisory panel. The advisory panel consisted of experienced consultant-level clinical psychologists of Māori and non-Māori descent. In addition, the advice of mental health consumers and elders (kaumatua) with advanced cultural knowledge was sought. Broadly speaking the structure of treatment involved an initial focus on implementing behavioural interventions followed by a focus on cognitive techniques commonly associated with CBT.
Each session lasted approximately 1 hour. The participants attended an average of 8.8/12 sessions; however, after removing a subject who only attended two sessions this average increased to 9.2/12 sessions. The number of sessions attended by each participant can be seen in Table 1.
Clinical staff (psychiatrists and care managers) from Māori Mental Health Services were oriented to the study. Clients who met inclusion criteria for referral to the study, were given information to read and discuss with their family. On all occasions the initial approach to potential participants was made through the case manager who facilitated the early stages of engagement with potential participants.
At the time that fieldwork was undertaken the first author was a Māori senior clinical psychologist with 7 years clinical experience in both mainstream and specialist Māori mental health clinical settings.
Treatment
The 12-session treatment manual that was developed for the purposes of this study incorporated a number of specific Māori values into the approach to treatment. These were conceptualized in terms of a series of domains as outlined below
The domain of connectedness (Whakawhanaungatanga). Current trends in international research suggest that a degree of therapist self-disclosure can have a positive impact on the therapeutic alliance and treatment outcome (e.g. Barrett & Berman, Reference Barrett and Berman2001; Knox & Hill, Reference Knox and Hill2003). The sentiments of the advisory panel were consistent with the research and literature recommending adaptation of CBT with ethnic minority groups which suggests that the sharing of personal information between the therapist and client is encouraged as part of the initial engagement with Latino clients (Organista, Reference Organista, Hays and Iwamasa2006; Interian & Díaz-Martínez, Reference Interian and Díaz-Martínez2007).
CBT has been characterized by a more active deportment on the part of the therapist that allows for higher levels of emotional support and empathy than would be typical of the insight-oriented therapies (Keijsers et al. Reference Keijsers, Schaap and Hoogduin2000). Despite this, therapist self-disclosure is a seldom used technique in CBT; for instance one study comparing CBT and insight-oriented therapies found no significant difference in the frequency of therapist self-disclosures (Stiles et al. Reference Stiles, Shapiro and Firth-Cozens1988). Reservations have also been raised regarding the clinical benefits of self-disclosure by the therapist with one review concluding that research findings suggested therapist self-disclosure was not a powerful therapeutic intervention (Orlinsky & Howard, Reference Orlinsky and Howard1987).
The information disclosed to clients participating in this study included tribal affiliation, working history, and family background. Where personal connections were made, or similarities identified between the client and the therapist these were acknowledged and further discussed. For example, were it to emerge from the self-disclosure process that the client and therapist were from the same tribe, these similarities would be acknowledged and discussed with reference to any connections of significance. The goal of these disclosures was described by one of the advisory group as a crucial part of the process of whakawhanaungatanga and an integral part of working effectively with Māori clients.
The domain of spirituality (Te taha wairua). In the current study Māori proverbs (whakatauki) or Māori prayer (karakia) were utilized to open and close sessions with clients. Rather than these being seen as a purely ritualistic or procedural, proverbs or prayer were selected that had some relevance to the phase of treatment and were explained and discussed with the client.
The domain of extended family (Te taha whānau). The notion that family can play a protective role in relation to mental illness and stress has long been promoted by Māori academics (e.g. Durie, Reference Durie1999; Herbert, Reference Herbert2001; Diamond, Reference Diamond2005; Pitama et al. Reference Pitama, Robertson, Cram, Gillies, Huria and Dallas-Katoa2007) and Te taha whānau is one of Durie's (Reference Durie1984) proposed cornerstones of Māori health. In his related commentary Hirini (Reference Hirini1997) pointed out that the individualized and thus less collective focus of CBT was a potential barrier to engaging effectively with Māori clients and their whānau. He gave the example that CBT interventions which fostered independent thought or assertiveness may contradict collective Māori values. Past authors have likewise highlighted that the individual focus of Western psychotherapies reflects the more individualistic and independent culture of Western society (e.g. Gelman, Reference Gelman2004). This has, however, been contrasted with, for example, the cultural perspective of eastern cultures who place a greater emphasis on mutual dependence and loyalty to one's family (Toukmanian & Brouwers, Reference Toukmanian, Brouwers, Kazarian and Evans1998).
Therefore for the purposes of the current study a more inclusive approach to treatment was utilized. This included extending an invitation to participants in the initial appointment letter to bring whānau support to initial sessions and involving whānau as active participants in treatment objectives (e.g. participating in behavioural experiments).
The domain of metaphor (Whaikōrero). The majority of psycho-educational material utilized by clinical psychologists uses Eurocentric examples to illustrate important cognitive behavioural concepts such as the connection between thoughts and emotions. An example of this is the psycho-educational material information used in the popular CBT manual Mind Over Mood (Greenberger & Padesky, Reference Greenberger and Padesky1995). Mind Over Mood uses a series of vignettes to illustrate the key tenets of CBT in an applied manner. However, the vignettes and associated characters utilized tend to reflect mainstream cultural influences in the USA. While this may be an understandable reflection of the original target audience, this becomes a limitation when used beyond that context. Vignettes were therefore utilized that were deemed more resonant with Māori experience in New Zealand.
Furthermore, ‘culturally appropriate’ metaphor in the form of Māori proverbs also known as whakatauki, were incorporated. A series of appropriate proverbs were identified that had relevance to the therapeutic goals of CBT and these were also incorporated into treatment.
Results
Table 2 presents the treatment completer data for the BDI-II and ATQ scales. It displays pre- and post-treatment BDI-II means and standard deviations for the paired samples. These statistics allow us to determine the ‘direction’ of any difference between means. The table shows that the mean pre-treatment BDI-II score is higher than the 1-month and 6-month post-treatment scores indicating that on average depressive symptoms decreased following the intervention. Mean depression scores decreased from mean = 28.69 (s.d. = 11.15) pre-treatment to mean = 10.71 (s.d. = 13.86) post-treatment. This reduction was sustained at 6-month follow-up with mean depression scores of 10.93 (s.d. = 14.81).
Table 2. Mean scores in clinical outcome measures across assessment points
BDI-II, Beck Depression Inventory – II; ATQ, Automatic Thought Questionnaire.
Furthermore, ATQ scores displayed a negative trend whereby post-treatment and follow-up scores were lower than the baseline scores. This indicates that negative rumination reduced as a consequence of the treatment. From pre-treatment to post-treatment mean ATQ scores reduced from 97.50 (s.d. = 25.48) to 71.21 (s.d. = 28.56)Footnote †. Six-month follow-up scores indicated that this was sustained with scores of mean = 65.93 (s.d. = 28.22).
The Wilcoxon signed rank test is a non-parametric test that is used as an alternative to the Student's t test for comparing means when the normal distribution of the sample cannot be assumed. A study in the area of CBT adaptation for minority cultural groups that used the same design as the current research (Interian et al. Reference Interian, Allen, Gara and Escobar2008) utilized the Wilcoxon test to compare means. The Wilcoxon statistics for this dataset are presented in Table 3.
Table 3. Wilcoxon statistics comparing pre-treatment means with post-treatment and follow-up data
BDI-II, Beck Depression Inventory – II; ATQ, Automatic Thought Questionnaire.
**p<0.01.
The Wilcoxon test showed that the difference between baseline and post-treatment scores were significant for both of the clinical outcome variables. In addition the 6-month follow-up data for the BDI-II and the ATQ was significantly different from baseline data. These findings further corroborate the t test results, which indicated a significant difference between the means of pre- and post-treatment scores.
Having established that a significant difference between means existed for each of the clinical outcome measures administered as part of the assessment, treatment effects were calculated for the clinical outcome variables. A Hedges’ g effect size calculation was conducted on both of the dependent variables related to clinical outcome. Table 4 presents the adjusted value for Hedges’ g for the BDI-II and ATQ as well as the change effect size which was calculated by dividing the average difference between means by the standard deviation of the difference scores. (Two effect sizes were calculated to facilitate the comparison of these findings with studies that utilized between-subjects methodology.)
Table 4. Effect size statistics for clinical outcome measures using three different standardizers
ES, Effect size; BDI-II, Beck Depression Inventory – II; ATQ, Automatic Thought Questionnaire.
Cohen (Reference Cohen1988) tentatively defined effect sizes between 0.2 and 0.3 as small, around 0.5 as medium, and greater than 0.8 as large. Using these criteria it can be inferred that large treatment effect sizes were observed for the BDI-II and ATQ. These large treatment effects were observed in comparing baseline data with both post-treatment and follow-up data.
Discussion
This study has investigated the effectiveness of a culturally adapted CBT treatment protocol with a group of clinically depressed Māori from a Community Mental Health Service in the Wellington region of New Zealand. Statistical analyses conducted on the grouped data showed that the reductions in mean scores for depressive symptoms and negative cognition following treatment were significant. Treatment effect statistics were calculated for both of the clinical outcome measures administered. All of the effect size statistics indicated that the intervention had a significant impact on reducing depressive symptoms and negative cognition.
There are, however, some limitations of this research that must be acknowledged. Significant among these was that this was a naturalistic study without a true control group. A larger scale study into the adaptation of CBT with Māori might utilize a between-subjects design and administer a non-adapted version of CBT to a control group. Despite the fact that Māori are over-represented in negative mental health statistics pertaining to the diagnosis of depression, we are still some way from being able to provide an inherently ‘Māori definition’ of the depression construct. This was beyond the scope of the current study; however, it is acknowledged that utilizing DSM criteria and measuring symptoms with psychometric instruments based in Western ideology is not ideal for a study that adapts CBT on the basis of assumed deficits in Western models of treatment.
Significant differences between baseline and post-treatment scores, and baseline and follow-up scores on all of the clinical outcome measures that were analysed provid strong support for the effectiveness of the intervention and thus the cultural adaptation of CBT for Māori. These findings of significant change raise a number of issues that can be considered from several angles.
It could be argued that these findings are not entirely surprising given the weight of international literature that validates CBT as an effective intervention for depression. However, it should be noted that this research is the first effectiveness study evaluating the individual delivery of CBT exclusively with Māori clients. The findings therefore represent a highly relevant and original contribution to our knowledge regarding effective treatment and ‘best practice’ with depressed Māori clients.
In comparing the effect sizes obtained in this study with those reported in other research, it is important that comparable statistics are used (i.e. those that have been calculated in the same metric). Two different effect sizes were calculated in order that the findings could be compared with studies that used a repeated-measures design (i.e. the ‘change’ effect size) and those that used a between-subjects design (i.e. Hedges’ g). This study did not include a between-subjects control and therefore the most meaningful comparisons should be made comparing the ‘change’ effect size obtained in this study with those reported by other studies that have used a within-subjects design.
Studies that employed a within-subjects design to examine the efficacy of CBT have tended to report large effect sizes. The current research compares favourably with within-subjects studies which have applied CBT in general clinical settings (e.g. Gloaguen et al. Reference Gloaguen, Cottraux, Cucherat and Blackburn1998). In their study, which employed an almost identical design in investigating the efficacy of CBT with a minority ethnic group, Interian et al. (Reference Interian, Allen, Gara and Escobar2008) reported very large effect sizes in relation to depressive symptoms. Specifically these effect sizes were 2.71 comparing pre-treatment with post-treatment and 2.53 comparing pre-treatment with 6-month follow-up. While these values are considerably higher than the change effect size calculated for the current study (1.62 and 1.66, respectively) these authors used a different moderator (i.e. the baseline standard deviation) in calculating their effect sizes. When the pooled standard deviation is applied these effect sizes reduce to the more comparable values of 1.79 (pre-treatment to post-treatment) and 1.76 (pre-treatment to follow-up).
It is also worthwhile contrasting the results with those that have compared CBT with a waitlist or no-treatment control. A meta-analysis of 20 such studies examining the efficacy of CBT for depression, reported an overall effect size of 0.82 (Gloaguen et al. Reference Gloaguen, Cottraux, Cucherat and Blackburn1998) considerably lower than the Hedges’ g effect sizes calculated for this study (1.40 and 1.42). While caution should be exercised in comparing the results of this research with those reported in studies that have employed between-subjects designs, it could be inferred from these comparisons that appropriately delivered CBT can be at least as effective in treating depression in Māori as the international outcome literature would suggest.
An important aspect that distinguishes this study from other research examining CBT with minority groups is that it employed a culturally adapted version of CBT. Therefore in drawing inferences from this research it should be highlighted that the findings provide empirical support for a form of CBT that has been culturally tailored specifically for the participants who received the treatment. Conversely, it cannot be assumed that these findings support the use of generic forms of CBT with Māori. This has clear implications for those who purport to work from a scientist-practitioner model as it provides support for culturally adapted CBT when working with Māori clients but stops short of supporting more general versions of CBT. We acknowledge that, this was an artefact of the research design which ideally would have included a standard CBT group as a control. However, in comparing the results of this study with others that have delivered generic/non-adapted forms of CBT to ethnic minority groups (e.g. Organista et al. Reference Organista, Muñoz and González1994; Miranda et al. Reference Miranda, Bernal, Lau, Kohn, Hwang and LaFromboise2005), it is possible to infer that making specific adaptations as has been done in this study leads to better treatment outcomes in ethnic minority populations. In this respect the findings are congruent with those of Interian et al. (Reference Interian, Allen, Gara and Escobar2008), Otto et al. (Reference Otto, Hinton, Korbly, Chea, Ba, Gershuny and Pollack2003), and Hinton et al. (Reference Hinton, Pham, Tran, Safren, Otto and Pollack2004) who all reported significant changes in key outcome areas and large effect sizes after adapting CBT for use with specific populations.
The conclusions of this research make a distinctive contribution to the literature on psychological treatment of ethnic minority populations. Epidemiological studies from around the world would suggest that most countries are yet to refine their mental health services to fully meet the needs of their indigenous and ethnic minority populations. However, the findings of this study provide strong support for the notion that cultural adaptation of psychological therapy can be associated with positive treatment outcomes for Māori. After all, there can be little question that the provision of a mental health service which not only acknowledges but actively celebrates the uniqueness of a client's ethnic identity represents a state of affairs to be highly coveted.
Acknowledgements
The authors gratefully acknowledge the generous support of the Health Research Council of New Zealand (HRC) who made this research possible through the award of a Clinical Research Fellowship to the first author.
Declaration of Interest
None.
Learning objectives
1. An introduction to considerations in the adaptation of CBT with Māori.
2. Provide guidelines for clinicians wishing to provide culturally sensitive evidence based practice to minority cultural groups.
3. Orient the reader to alternate quantitative methodology for trialling innovative practice with ‘high need’ but relatively small populations.
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