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Clinical Psychological Science

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• translational research, which recognizes that mental illness is grounded in disruption of basic psychological processes (e.g., cognition, emotion, socialization, personality, perception, learning, motivation, development)
• transdiagnostic approaches, which focus on disrupted processes that are common to different forms of psychopathology (e.g., sleep, emotion regulation and expression, attachment)
• empirically supported assessment, diagnosis, and treatment
• molecular and behavioral genetics and proteomics, which link common and uncommon variations in genes with behaviors relevant to psychopathology and well-being
• neuroimaging, which enables characterization of the integrity of neural networks and patterns of brain activation associated with normal and abnormal functioning and suggests new avenues for diagnosis and evaluation of treatment effects
• new treatments focusing on brain and behavior change (e.g., transmagnetic stimulation, direct neural stimulation, new drug and/or behavioral treatment delivery systems, gene-targeted therapies)

The journals of the Association for Psychological Science are sold as a package. View the details of the subscription package .

The Association for Psychological Science (APS) is the leading international organization dedicated to advancing scientific psychology across disciplinary and geographic borders. APS members provide a richer understanding of the world through their research, teaching, and application of psychological science. APS is passionate about supporting psychological scientists in these pursuits, which it does by sharing cutting-edge research across all areas of the field through its journals and conventions; promoting the integration of scientific perspectives within psychological science and with related disciplines; fostering global connections among its members; engaging the public with research to promote broader understanding and awareness of psychological science; and advocating for increased support for psychological science in the public policy arena. More than 30,000 leading psychological researchers, as well as students and teachers, have made APS their scientific home. www.psychologicalscience.org This journal is a member of the Committee on Publication Ethics (COPE) .

Clinical Psychological Science publishes advances in clinical science and provides a venue for cutting-edge research across a wide range of conceptual views, approaches, and topics. The Journal encompasses many core domains that have defined clinical psychology, but also boundary-crossing advances that integrate and make contact with diverse disciplines and that may not easily be found in traditional clinical psychology journals. Among the key topics are research on the underlying mechanisms and etiologies of psychological health and dysfunction; basic and applied work on the diagnosis, assessment, treatment, and prevention of mental illness; service delivery; and promotion of well-being.

This broadly based international Journal sits at the interface of clinical psychological science and other disciplines, publishing the best papers from the full spectrum of relevant science. The Journal welcomes empirical papers as well as occasional reviews and associated theoretical formulations addressing the following:

• Research from all areas of psychology and from all disciplines (e.g., genetics, neuroscience, psychiatry, public health, sociology) insofar as they relate to clinical psychology issues broadly conceived;
• Basic research on the psychological and related processes that are disrupted in psychopathology;
• Research on core areas of cognition, emotion, learning, memory, sensation, perception, and neuroscience that clearly addresses clinical phenomena;
• Research related to clinical issues at all levels of analysis (from genes and molecules to contexts and cultures), using the full range of behavioral and biological methods, and incorporating both human and non-human animal models;
• Research on specific clinical symptoms, syndromes, and diagnostic systems;
• Studies with clinical patient populations as well as studies using non-clinical or pre-clinical populations that are relevant to understanding clinical dysfunction;
• Basic and applied research relevant to clinical diagnosis, assessment, prevention, and treatment;
• Research focusing on precursors and risk factors for dysfunction as well as protective factors and resources that promote resilience and adaptive functioning;
• Cultural and ethnic studies that advance our understanding of processes that relate to development of mental health or dysfunction; and
•  Sophisticated, cross-cutting, and novel methodological, statistical, and mathematical approaches that enable advances in research.

These examples and all such approaches are critical components of the Journal. However, the very nature of what is meant by cutting-edge and the rapid advances in methods of assessment mean that its scope cannot be fully enumerated. The key criterion is that the research directly inform some facet of clinical psychology.

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Clinical Psychology Research Topics

Stumped for ideas? Start here

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Emily is a board-certified science editor who has worked with top digital publishing brands like Voices for Biodiversity, Study.com, GoodTherapy, Vox, and Verywell.

Clinical psychology research is one of the most popular subfields in psychology. With such a wide range of topics to cover, figuring out clinical psychology research topics for papers, presentations, and experiments can be tricky.

Clinical Psychology Research Topic Ideas

Topic choices are only as limited as your imagination and assignment, so try narrowing the possibilities down from general questions to the specifics that apply to your area of specialization.

Here are just a few ideas to start the process:

• How does social media influence how people interact and behave?
• Compare and contrast two different types of therapy . When is each type best used? What disorders are best treated with these forms of therapy? What are the possible limitations of each type?
• Compare two psychological disorders . What are the signs and symptoms of each? How are they diagnosed and treated?
• How does "pro ana," "pro mia," " thinspo ," and similar content contribute to eating disorders? What can people do to overcome the influence of these sites?​
• Explore how aging influences mental illness. What particular challenges elderly people diagnosed with mental illness face?
• Explore factors that influence adolescent mental health. Self-esteem and peer pressure are just a couple of the topics you might explore in greater depth.
• Explore the use and effectiveness of online therapy . What are some of its advantages and disadvantages ? How do those without technical literacy navigate it?
• Investigate current research on the impact of media violence on children's behavior.
• Explore anxiety disorders and their impact on daily functioning. What new therapies are available?
• What are the risk factors for depression ? Explore the potential risks as well as any preventative strategies that can be used.
• How do political and social climates affect mental health?
• What are the long-term effects of childhood trauma? Do children continue to experience the effects later in adulthood? What treatments are available for PTSD (post-traumatic stress disorder) in childhood ?
• What impact does substance use disorder have on the family? How can family members help with treatment?
• What types of therapy are most effective for childhood behavioral issues ?

Think of books you have read, research you have studied, and even experiences and interests from your own life. If you've ever wanted to dig further into something that interested you, this is a great opportunity. The more engaged you are with the topic, the more excited you will be to put the work in for a great research paper or presentation.

Consider Scope, Difficulty, and Suitability

Picking a good research topic is one of the most important steps of the research process. A too-general topic can feel overwhelming; likewise, one that's very specific might have limited supporting information. Spend time reading online or exploring your library to make sure that plenty of sources to support your paper, presentation, or experiment are available.

If you are doing an experiment , checking with your instructor is a must. In many cases, you might have to submit a proposal to your school's human subjects committee for approval. This committee will ensure that any potential research involving human subjects is done in a safe and ethical way.

Once you have chosen a topic that interests you, run the idea past your course instructor. (In some cases, this is required.) Even if you don't need permission from the instructor, getting feedback before you delve into the research process is helpful.

Your instructor can draw from a wealth of experience to offer good suggestions and ideas for your research, including the best available resources pertaining to the topic. Your school librarian may also be able to provide assistance regarding the resources available for use at the library, including online journal databases.

Kim WO.  Institutional review board (IRB) and ethical issues in clinical research .  Korean Journal of Anesthesiology . 2012;62(1):3-12. doi:10.4097/kjae.2012.62.1.3

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Clinical Health Psychology PhD Program

Mission statement.

The mission of the Clinical Health Psychology (CHP) program is to train Scientist-Practitioners who receive a generalist-training in clinical psychology, and who acquire additional knowledge and skill in health psychology and behavioral medicine. We promote a practice of clinical psychology that is evidence-based and integrates the findings of relevant scientific research. We encourage our students to engage in both research and clinical work, and to use critical analysis of the empirical literature to inform their clinical interventions. Our graduates are trained to function in a complex, diverse, and pluralistic society, emphasizing ethical principles and developing knowledge and respect for individual, group, and cultural differences.

Program Director : Amy Wachholtz, PhD                             

Program Assistant : Kimberly Hill , Ph.D.

CHP Admissions:   [email protected]

CU Denver and the College of Liberal Arts and Sciences have provided clear statements that we must stand together against racism and injustice. The Clinical Health Psychology program is aligned with these values. Please find here a helpful site of resources regarding racial justice.

The Psychology Department at CU Denver offers a Doctor of Philosophy degree (PhD) with an emphasis in Clinical Health Psychology (CHP). We are accredited by the American Psychological Association (APA) since 2016 (APA, Office of Program Consultation and Accreditation, 750 1st St. NE, Washington, DC 20002-4242; 202.336.5979). Our next site visit is Winter/Spring 2024.  Our program adheres to the scientist-practitioner model. Training emphasizes the contribution of research to the understanding, treatment and prevention of a wide range of health-related concerns, and the application of knowledge that is grounded in scientific evidence.  

In the CHP program, students are trained in a variety of approaches and techniques for evaluating, diagnosing and treating a wide range of psychological problems. Because our program places an emphasis on health, our students are also trained to assess the psychological factors associated with different medical conditions and learn to design effective interventions that integrate biological, psychological and social (including cultural) factors. Students acquire research expertise by completing a master's thesis and doctoral dissertation and demonstrate competence in clinical assessment and intervention through several applied practica experiences, a clinical competency evaluation, and a pre-doctoral internship. With this broad and intense model of training, our students have gone on to diverse professional postdoctoral fellowships and professional careers. Examples of research opportunities, clinical training opportunities, and post graduate experiences for our students can be found here.

CU Denver is a premier research university in Colorado and the PhD program in CHP was conceived as an important bridge between the Downtown Campus and the Anschutz Medical Campus (AMC).  The program is housed on the Downtown Campus which is located in the heart of Denver close to the Denver Center for the Performing Arts, the LoDo District and the state capital.  The Anschutz Medical Campus includes over 5 million square feet of research, educational and clinical space on 227 acres.  The PhD program offers research and clinical opportunities for its students at AMC in addition to the many relationships it has established with other clinical facilities in the Denver area.

The University of Colorado Denver’s CHP program is committed to diversity and fostering inclusion; one in which all individuals- whether from underrepresented, represented, or well represented groups- feel uniquely esteemed, valued and respected.  As psychologists, we understand that a culture of inclusion encourages diverse perspectives and makes our program and students stronger. This is part of our mission to equip future researchers and clinicians to be culturally competent and responsive as they engage in the science and practice of psychology.  Cultural competence and responsiveness in both research and clinical practice is strongly emphasized in our curriculum, clinical training, research, and numerous events in both the University and Denver communities. In our large urban setting, students in our program have excellent opportunities in to expand their research and clinical experience in with regard to diverse and underserved populations, including opportunities in bilingual training. Moreover, students and faculty in the program have a wide range of research interests, including research focused on neurodiversity, varying developmental periods, religious diversity, military couples, physical ability and addiction status, and health and healthcare disparities. Student research regarding diversity is encouraged. Applicants and current students can click the link below for more information about diversity programs at CU Denver.

Office of Diversity and Inclusion

Licensure information:

We are an APA accredited program (APA, Office of Program Consultation and Accreditation, 750 1st St. NE, Washington, DC 20002-4242; 202.336.5979) and most states and territories in the United States use APA requirements for licensing psychologists, including the state of Colorado.  However, as state requirements may change without any notice to doctoral programs, we are unable to confirm that our program meets the licensure requirements for any specific state or territory.  If you intend to pursue such credentialing and licensing in a different state or territory, we advise you to contact the applicable state credentialing authority to familiarize yourself with its specific requirements and determine if our program meets its eligibility criteria.  Many students find the following link is a helpful place to start in researching a state or territory’s requirements:   https://www.asppb.net/page/BdContactNewPG  . If you have further questions, you are welcome to contact the program director,  Amy Wachholtz, PhD , or the program assistant,  Kimberly Hill  and we will do our best to assist you in your career planning.       

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The Science of Psychology

5 Experimental and Clinical Psychologists

Learning objectives.

• Define the clinical practice of psychology and distinguish it from experimental psychology.
• Explain how science is relevant to clinical practice.
• Define the concept of an empirically supported treatment and give some examples.

Who Conducts Scientific Research in Psychology?

Experimental psychologists.

Scientific research in psychology is generally conducted by people with doctoral degrees (usually the  doctor of philosophy [Ph.D.] ) and master’s degrees in psychology and related fields, often supported by research assistants with bachelor’s degrees or other relevant training. Some of them work for government agencies (e.g., doing research on the impact of public policies), national associations (e.g., the American Psychological Association), non-profit organizations (e.g., National Alliance on Mental Illness), or in the private sector (e.g., in product marketing and development; organizational behavior). However, the majority of them are college and university faculty, who often collaborate with their graduate and undergraduate students. Although some researchers are trained and licensed as clinicians for mental health work—especially those who conduct research in clinical psychology—the majority are not. Instead, they have expertise in one or more of the many other subfields of psychology: behavioral neuroscience, cognitive psychology, developmental psychology, personality psychology, social psychology, and so on. Doctoral-level researchers might be employed to conduct research full-time or, like many college and university faculty members, to conduct research in addition to teaching classes and serving their institution and community in other ways.

Of course, people also conduct research in psychology because they enjoy the intellectual and technical challenges involved and the satisfaction of contributing to scientific knowledge of human behavior. You might find that you enjoy the process too. If so, your college or university might offer opportunities to get involved in ongoing research as either a research assistant or a participant. Of course, you might find that you do not enjoy the process of conducting scientific research in psychology. But at least you will have a better understanding of where scientific knowledge in psychology comes from, an appreciation of its strengths and limitations, and an awareness of how it can be applied to solve practical problems in psychology and everyday life.

Scientific Psychology Blogs

A fun and easy way to follow current scientific research in psychology is to read any of the many excellent blogs devoted to summarizing and commenting on new findings. Among them are the following:

Research Digest, http://digest.bps.org.uk/ Talk Psych, http://www.talkpsych.com/ Brain Blogger, http://brainblogger.com/ Mind Hacks, http://mindhacks.com/ PsyBlog, http://www.spring.org.uk

You can also browse to http://www.researchblogging.org , select psychology as your topic, and read entries from a wide variety of blogs.

Clinical Psychologists

Psychology is the scientific study of behavior and mental processes. But it is also the application of scientific research to “help people, organizations, and communities function better” (American Psychological Association, 2011) [1] . By far the most common and widely known application is the clinical practice of psychology — the diagnosis and treatment of psychological disorders and related problems. Let us use the term  clinical practice  broadly to refer to the activities of clinical and counseling psychologists, school psychologists, marriage and family therapists, licensed clinical social workers, and others who work with people individually or in small groups to identify and help address their psychological problems. It is important to consider the relationship between scientific research and clinical practice because many students are especially interested in clinical practice, perhaps even as a career.

The main point is that psychological disorders and other behavioral problems are part of the natural world. This means that questions about their nature, causes, and consequences are empirically testable and therefore subject to scientific study. As with other questions about human behavior, we cannot rely on our intuition or common sense for detailed and accurate answers. Consider, for example, that dozens of popular books and thousands of websites claim that adult children of alcoholics have a distinct personality profile, including low self-esteem, feelings of powerlessness, and difficulties with intimacy. Although this sounds plausible, scientific research has demonstrated that adult children of alcoholics are no more likely to have these problems than anybody else (Lilienfeld et al., 2010) [2] . Similarly, questions about whether a particular psychotherapy is effective are empirically testable questions that can be answered by scientific research. If a new psychotherapy is an effective treatment for depression, then systematic observation should reveal that depressed people who receive this psychotherapy improve more than a similar group of depressed people who do not receive this psychotherapy (or who receive some alternative treatment). Treatments that have been shown to work in this way are called empirically supported treatments .

Empirically Supported Treatments

An empirically supported treatment is one that has been studied scientifically and shown to result in greater improvement than no treatment, a placebo, or some alternative treatment. These include many forms of psychotherapy, which can be as effective as standard drug therapies. Among the forms of psychotherapy with strong empirical support are the following:

• Acceptance and committment therapy (ACT) . for depression, mixed anxiety disorders, psychosis, chronic pain, and obsessive-compulsive disorder.
• Behavioral couples therapy. For alcohol use disorders.
• Cognitive behavioral therapy (CBT). For many disorders including eating disorders, depression, anxiety disorders, etc.
• Exposure therapy. For post-traumatic stress disorder and phobias.
• Exposure therapy with response prevention.  For obsessive-compulsive disorder.
• Family-based treatment. For eating disorders.

For a more complete list, see the following website, which is maintained by Division 12 of the American Psychological Association, the Society for Clinical Psychology: http://www.div12.org/psychological-treatments

Many in the clinical psychology community have argued that their field has not paid enough attention to scientific research—for example, by failing to use empirically supported treatments—and have suggested a variety of changes in the way clinicians are trained and treatments are evaluated and put into practice. Others believe that these claims are exaggerated and the suggested changes are unnecessary (Norcross, Beutler, & Levant, 2005) [3] . On both sides of the debate, however, there is agreement that a scientific approach to clinical psychology is essential if the goal is to diagnose and treat psychological problems based on detailed and accurate knowledge about those problems and the most effective treatments for them. So not only is it important for scientific research in clinical psychology to continue, but it is also important for clinicians who never conduct a scientific study themselves to be scientifically literate so that they can read and evaluate new research and make treatment decisions based on the best available evidence.

• American Psychological Association. (2011). About APA . Retrieved from http://www.apa.org/about ↵
• Lilienfeld, S. O., Lynn, S. J., Ruscio, J., & Beyerstein, B. L. (2010). 50 great myths of popular psychology . Malden, MA: Wiley-Blackwell. ↵
• Norcross, J. C., Beutler, L. E., & Levant, R. F. (Eds.). (2005). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions . Washington, DC: American Psychological Association. ↵

An academic degree earned through intensive study of a particular discipline and the completion of a set of research studies that contribute new knowledge to the academic literature.

The diagnosis and treatment of psychological disorders and related problems.

A treatment that that has been shown through systematic observation to lead to better outcomes when compared to no-treatment or placebo control groups.

Research Methods in Psychology Copyright © 2019 by Rajiv S. Jhangiani, I-Chant A. Chiang, Carrie Cuttler, & Dana C. Leighton is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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The Case for Cultural Competency in Psychotherapeutic Interventions

Stanley sue.

1 Department of Psychology, University of California, Davis, California 95616

Gordon C. Nagayama Hall

2 Department of Psychology, University of Oregon, Eugene, Oregon 97403

Lauren K. Berger

Cultural competency practices have been widely adopted in the mental health field because of the disparities in the quality of services delivered to ethnic minority groups. In this review, we examine the meaning of cultural competency, positions that have been taken in favor of and against it, and the guidelines for its practice in the mental health field. Empirical research that tests the benefits of cultural competency is discussed.

INTRODUCTION

The notion that culturally competent services should be available to members of ethnic minority groups has been articulated for at least four decades. Multiculturalism, diversity, and cultural competency are currently hot and important topics for mental health professionals ( Pistole 2004 , Whaley & Davis 2007 ). Originally conceptualized as cultural responsiveness or sensitivity, cultural competency is now advocated and, at times, mandated by professional organizations; local, state, and federal agencies; and various professions. Yet, the concept has also been a source of controversy concerning its necessity, empirical research base, and political implications. This review examines many of the key issues surrounding cultural competency—namely, its definition, rationale, empirical support, and effects. We have not attempted to be exhaustive in our review of the relevant research; instead, we have examined the major issues and trends in cultural competency.

Many prominent health care organizations are now calling for culturally competent health care and culturally competent professionals ( Herman et al. 2004 ). Appeals for cultural competency grew out of concerns for the status of ethnic minority group populations (i.e., African Americans, American Indians and Alaska Natives, Asian Americans, and Hispanics). These concerns were prompted by the growing diversity of the U.S. population, which necessitated changes in the mental health system to meet the different needs of multicultural populations. Further troubling were the welldocumented health status disparities between different ethnic and racial groups, as well as the nationally publicized studies regarding cultural bias in health care decision making and recommendations ( Schulman et al. 1999 ). The evidence revealed that mental health services were not accessible, available, or effectively delivered to these populations. Compared to white Americans, ethnic minority groups were found to underutilize services or prematurely terminate treatment ( Pole et al. 2008 , Sue 1998 ). Racial and ethnic minorities receive a lower quality of health care than do nonminorities, have less access to care, and are not as likely to be given effective, state-of-the-art treatments ( U.S. Surgeon General 2001 ). The disparities exist because of service inadequacies rather than any possible differences in need for services or access-related factors, such as insurance status ( Smedley et al. 2003 ).

Justice or ethical grounds have also propelled cultural competency ( Whaley & Davis 2007 ). The goals of many professional organizations include equity and fairness in the delivery of services. For example, one of the guiding principles of the American Psychological Association (2002 , pp. 1062–1063) is that:

Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists. Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices.

Ridley (1985) has argued that cultural competence is an ethical obligation and that crosscultural skills should be placed on a level of parity with other specialized therapeutic skills. As an alternative to the passive “do no harm” approach in ethical standards in many helping professions, Hall et al. (2003) advocated that ethical standards mandate cultural competence via collaboration with, and sometimes deference to, ethnic minority communities and experts.

The delivery of quality services is especially difficult because of cultural and institutional influences that determine the nature of services. For example, Bernal & Scharroón-Del-Río (2001) maintain that ethnic and cultural factors should be considered in psychosocial treatments for many reasons. They propose that psychotherapy itself is a cultural phenomenon that plays a key role in the treatment process. In addition, ethnic and cultural concepts may clash with mainstream values inherent to traditional psychotherapies. The sources of treatment disparities are complex, are based on historic and contemporary inequities, and involve many players at several different levels, including health systems, their administrative and bureaucratic processes, utilization managers, health care professionals, and patients ( Smedley et al. 2003 ).

Although the problems giving rise to the cultural competency movement are multifaceted, our focus in this review is to analyze therapist and treatment tactics that are considered culturally competent. In the focus on cultural competency, we acknowledge the social and psychological diversity that exists among members of any ethnic minority group and the tendency to generalize information across distinct ethnic groups. The discussion of cultural competence issues for a particular ethnic minority group becomes even more challenging in view of the limited amount of empirically based information available on cultural influences in mental health treatment. Considering these limitations, we proceed as judiciously as we can, examining key cultural tendencies and issues likely to be encountered in psychotherapy and counseling, drawing out some implications from the extant research, and offering some suggestions for research that may produce more culturally informed mental health practices. We also recognize that culture is only one relevant factor in providing effective mental health treatment and that depending on the circumstances, other aspects of clients may be more influential. The literature reviewed represents trends that have been observed and should be considered as guidelines or working hypotheses often linked with culturally competent mental health care for ethnic minority clientele.

WHAT IS CULTURAL COMPETENCY?

From the outset, we want to indicate that our coverage is limited. In cultural competence, it is important to distinguish between three levels of analysis: provider and treatment level, agency or institutional level (e.g., the operations of a mental health agency), and systems level (e.g., systems of care in a community). Our focus is on the first level—that of the provider, therapist, or counselor and that of the specific treatment used.

To evaluate the validity, utility, and empirical basis of cultural competency, one must first be able to define the construct. Competence is usually defined as an ability to perform a task or the quality of being adequately prepared or qualified. If therapists or counselors are generally competent to conduct psychotherapy, they should be able to demonstrate their skills with a range of culturally diverse clients. Proponents of cultural competency, however, believe that competency is largely a relative skill or quality, depending on one’s cultural expertise or orientation. Their definitions of cultural competency assume that expertise or effectiveness in treatment can differ according to the client’s ethnic or racial group. As Hall (2001) noted, advocates of cultural competency or sensitivity appreciate the importance of cultural mechanisms and argue that simply exporting a method from one cultural group to another is inadequate.

Can Cultural Competency be Distinguished from Competency in General?

Is there evidence that cultural competency can be distinguished from competency in general? The two may overlap but also have some distinct effects. Fuertes and colleagues (2006) found that ethnic minority clients rated their therapists as being higher in multicultural competency if the therapists were rated high on therapeutic alliance and empathy. These two characteristics are considered good ingredients in all treatments. Fuertes et al. (2006) recommend that therapists receive training in traditional areas such as relationship building and in communicating empathy. At the same time, they believe it is important that therapists be trained to competently handle the culturebased concerns that their clients bring to therapy. Another study suggests that the two are somewhat distinct. Constantine (2002) correlated African American, American Indian, Asian American, and Hispanic clients’ treatment satisfaction with two measures of competency: one that assessed counselors’ competency in general (i.e., the Counselor Rating Form–Short) and the other that measured cross-cultural competence in particular (Cross-Cultural Counseling Inventory–Revised). Although the two wellestablished competency measures were somewhat related, the cross-cultural competency measure contributed significantly to client satisfaction beyond general competency. There was also evidence that ethnic minority clients’ perceptions of their counselors’ multicultural counseling competence partially mediated the relationship between general counseling competence ratings and satisfaction with counseling. Thus, cultural competency may be meaningfully distinguished from competency in general.

Differing Definitions

But how does one define the concept? In the past, terms such as “cultural sensitivity,” “cultural responsiveness,” and “multicultural competence” were used to convey the significance of attending to cultural issues in therapy and counseling. Despite consensus over the importance and significance of cultural values and behaviors in treatment, investigators have actually varied in their specific assumptions or focus for cultural competency. Many models of culturally sensitive therapy have been developed ( Hall et al. 2003 ). Some describe characteristics of cultural competency. For example, ingredients viewed by some as essential for cultural competence include having an understanding, appreciation, and respect for cultural differences and similarities within, among, and between culturally diverse patient groups ( U.S. Dept. Health Human Serv. 2002 ). Culturally competent care has been defined as a system that acknowledges the importance and incorporation of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaptation of interventions to meet culturally unique needs ( Whaley & Davis 2007 ).

Others emphasize the outcome of cultural expertise. Thus, having cultural knowledge or skills is important to the extent that positive outcomes are achieved, such as:

• The capacity to perform and obtain positive clinical outcomes in cross-cultural encounters ( Lo & Fung 2003 ).
• The acquisition of awareness, knowledge, and skills needed to function effectively in a pluralistic democratic society (i.e., the ability to communicate, interact, negotiate, and intervene on behalf of clients from diverse backgrounds) ( Alvarez & Chen 2008 , D.W. Sue & Torino 2005 ).
• The possession of cultural knowledge and skills of a particular culture to deliver effective interventions to members of that culture ( S. Sue 1998 ).
• The ability to work effectively in crosscultural situations using a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals ( Agency for Healthcare Research and Quality 2004 ).

Although the varying definitions overlap to some degree, one meaningful way of conceptualizing the definitions of competency is to note that some emphasize the ( a ) kind of person one is, ( b ) skills or intervention tactics that one uses, or ( c ) processes involved. In terms of the kind of person one is, D.W. Sue and colleagues ( Sue et al. 1982 , 1992 ) argue that the culturally competent counselor has:

• Cultural awareness and beliefs: The provider is sensitive to her or his personal values and biases and how these may influence perceptions of the client, the client’s problem, and the counseling relationship.
• Cultural knowledge: The counselor has knowledge of the client’s culture, worldview, and expectations for the counseling relationship.
• Cultural skills: The counselor has the ability to intervene in a manner that is culturally sensitive and relevant.

In this view, cultural competency involves a constellation of the right personal characteristics (awareness, knowledge, and skills) that a counselor or therapist should have. Every counselor should possess these characteristics. This model for cultural competency is the most widely recognized framework, and it formed the basis for much of the multicultural guidelines adopted by the American Psychological Association ( Am. Psychol. Assoc. 2003 ) as well as the multicultural counseling competencies adopted by the organization’s Division 17.

The skills or tactics model views cultural competency as a skill to be learned or a strategy to use in working with culturally diverse clients. One chooses to exercise the skill or to use a cultural adaptation under the appropriate circumstances. Cultural competency is essentially similar to other specialized therapeutic skills such as expertise in sexual dysfunctions and depressive disorders ( Ridley 1985 ). In this view, acquisition of multicultural competence would involve in-depth training and supervised experience as found in the development of other psychotherapeutic competencies ( Whaley & Davis 2007 ).

Finally, process-oriented models focus on the complex client-therapist-treatment interactions and processes involved. For example, López (1997) considers the essence of cultural competence to be “the ability of the therapist to move between two cultural perspectives in understanding the culturally based meaning of clients from diverse cultural backgrounds” (p. 573). S. Sue (1998) views cultural competence as a multidimensional process. He proposes that three important characteristics underlie cultural competency among providers: scientific mindedness (i.e., forming and testing hypotheses), dynamic sizing (i.e., flexibility in generalizing and individualizing), and culturespecific resources (i.e., having knowledge and skills to work with other cultures) in response to different kinds of clients.

The definitions of cultural competence have points of convergence and divergence ( Whaley & Davis 2007 ). They all agree that knowledge, skills, and problem solving germane to the cultural background of the help seeker are fundamental. Nevertheless, the different definitions vary with respect to their emphasis on global characteristics, knowledge, skills, awareness, problem-solving abilities, aspirations, processes, etc. The definitions also vary as to how amenable they are to research testing. The kind-of-person model and the process model pose problems in terms of empirical testing. In both models, characteristics of culturally competent therapists or interacting processes are difficult to specify and operationalize for research. On the other hand, the skills or cultural adaptation model can be more readily tested. In this model, researchers introduce the skill or cultural adaptation of treatment and compare the effects with other treatment or no-treatment control groups.

In general, it has been difficult to develop research strategies, isolate components, devise theories of cultural competency, and implement training strategies. Some limitations in cultural sensitivity or competency are that it ( a ) has various meanings, ( b ) includes inadequate descriptors, ( c ) is not theoretically grounded, and ( d ) is restricted by a lack of measurements and research designs for evaluating its impact in treatment.

RESISTANCE TO CULTURAL COMPETENCY

It is not surprising that cultural competency or multiculturalism has come under attack. Because of the lack of research on cultural competency, some have challenged it as being motivated by “political correctness” ( Satel & Forster 1999 ) and untested in clinical trials ( Satel 2000 ).

One of the important debates in the literature concerning cultural competency can be found in the attempt to establish multicultural counseling competencies or multicultural guidelines for the American Mental Health Counseling Association. The guidelines, many of which are highly similar to the ones adopted by the American Psychological Association (2003) , stimulated civil but contentious exchanges. The debated issues revolved around several key questions, articulated largely by Thomas & Weinrach (2004) , Weinrach & Thomas (2002 , 2004 ), Vontress & Jackson (2004) , and Patterson (2004) :

• Because cultural competency advocates emphasize the need to understand the cultural values and worldviews of members of different cultural groups, Weinrach & Thomas (2002 , 2004 ) have suggested that the position that members of these groups behave similarly is inadvertently racist, stereotypic, and prejudicial. Herman et al. (2007) and Hwang (2006) made similar points more recently. They ask whether it is possible to conduct culturally competent counseling given the risks associated with implementing counseling in a manner that fails to attend to a client’s individual differences and inadvertently promotes culture-related stereotypes of clients. For example, important individual differences among American Indian clients include ethnic identity, acculturation, residential situation, and tribal background ( Trimble 2003 , 2008 ). By addressing presumed cultural orientations of, say, American Indians, therapists may fail to consider acculturated American Indian clients who do not hold traditional Native American perspectives.
• The cultural competency movement, for the most part, has been addressed to the needs of African Americans, American Indians and Native Alaskans, Asian Americans, and Hispanics. Weinrach & Thomas (2002) believe that the designation of only a few minority groups as worthy of the profession’s attention is profoundly demeaning to those minorities not included and that the concerns of other diverse populations, such as women and persons with disabilities, are ignored.
• Weinrach & Thomas (2002 , 2004 ) have also raised the issue that multicultural proponents have emphasized that external or environmental forces, such as racism and oppression, largely cause clients’ emotional disturbance. Intrapsychic causes are minimized. Weinrach & Thomas argue that a focus on race is an outmoded notion. Race does not provide an adequate explanation of the human condition. Attempts to invoke race as such have been appropriately labeled as racist and inadvertently contribute to America’s preoccupation with the pigmentation of a person’s skin. Vontress & Jackson (2004) maintain that mental health counselors should look at all factors that affect a client’s situation. Race may or may not be one of them. They believe that in general, race is not the real problem in the United States today. The significance that clients attach to it is the most important consideration. However, Vontress & Jackson (2004) believe that in this country, the attention given to discussing cultural differences and similarities is good for society and for our profession.
• Finally, Patterson (2004) is concerned over the emphasis on cultural differences. He notes that it has not been fruitful to assume that simply having knowledge of the culture of the client will lead to more appropriate and effective therapy. The first faulty assumption is that counseling or psychotherapy is a matter of information, knowledge, practices, skills, or techniques. Rather, the competent mental health counselor is one who provides an effective therapeutic relationship. The second faulty assumption is that client differences are more important than client similarities. He argues that a treatment such as client-centered therapy is a universal system that cuts across cultures. However, methods that are considered universal usually are Western methods that are assumed to apply to other groups. Most Western therapeutic methods rely heavily on verbal and emotional expression. Yet, among persons of East Asian ancestry, talking has been found to interfere with thinking ( Kim 2002 ), and emotional expression may be dependent on cultural norms ( Chentsova-Dutton et al. 2007 ). In fact, recent research indicates that the psychological consequences of emotional suppression and control can differ depending on the cultural context ( Butler et al. 2007 ).
• Weinrach & Thomas (2004) have indicated that support for cultural competency, created as a logical consequence of the 1960s civil rights movement, is often used as a litmus test of one’s commitment to a nonracist society. Weinrach & Thomas (2004 , pp. 90–91) state:

Among other goals, they were intended to sensitize White mental health professionals to the unique cultural distinctiveness of male clients on the basis of membership in four visible minority groups. At the symbolic level, they have successfully brought to professional counselors’ awareness the importance of attending to the diverse counseling needs of visible minorities. On the applied level, they have been a failure, as we see it. We would prefer to see their demise in order to foster the recognition that client needs should not be assumed to be based upon group membership alone, but rather on the unique constellation of individual client characteristics, including but not limited to cultural distinctiveness.

They lament the fact that personswhorefuse to adopt the competencies may be accused of displaying “unintentional racism” or the results of “the insidious ethnocentric aspect of our cultural conditioning” (see Ivey & Ivey 1997 , D.W. Sue 1996 ).

Although heated at times, the debates in the literature have been instructive. First, they help to clarify positions and misunderstandings. For example, most advocates of cultural competency do not see external factors (e.g., racism) as the sole or primary cause of mental disorders or that attention to ethnicity and race lessens concern over other diversity or individual differences (e.g., gender, sexual orientation, social class, etc.) factors ( Arredondo & Toporek 2004 , Coleman 2004 ). They recognize individual differences within various ethnic groups, such as the multitude of groups considered Hispanic (e.g., Mexican, Puerto Rican, and Cuban American).Even within a particular group, such as Mexican Americans, there may be considerable variations in level of acculturation that affect the outcomes of cultural competency interventions, as we note below. The emphasis on ethnicity and race is a reaction to centuries of ethnocentric bias against, and inattention to, the importance of culture and minority group status. If, as Bernal & Scharrón-Del-Río (2001) have argued, psychotherapy itself is a cultural phenomenon, ethnic minority concepts may conflict with mainstream values inherent to traditional psychotherapies. Cultural values of interdependence and spirituality, and discrimination in the psychotherapy of ethnic minorities, are often ignored in treatment approaches to ethnic minority clients ( Hall 2001 ). In order to achieve the ecological validity of interventions, these cultural values must be considered in all treatments ( Bernal 2006 ). Given the growing ethnic minority populations and the existing disparities in health and treatment, special attention to race and ethnicity is needed.

Second, there is no single multicultural orientation or cultural competency viewpoint, as noted in our discussion of the definitions of cultural competency. Yet, critics often attack cultural competency by characterizing it with extreme positions (a straw man approach). Satel & Forster (1999) have asserted that the most radical vision of cultural competence claims that membership in an oppressed group is a client’s most clinically important attribute. This assertion is misleading because few, if any, would advocate such a view. In addition, cultural competency tactics appear to vary according to the kind of client and the kind of disorders experienced by the client (discussed below).

Third, discussions of culture, ethnicity and race, and multiculturalism are frequently heated and emotional. Emotional reactions to the issues are not unexpected. Race and ethnicity have been highly controversial throughout the history of the United States. As noted by Pope-Davis et al. (2001 , pp. 128–129):

It is our contention that multiculturalism is infused with political meaning. The word itself is a symbol—a trigger—of change that often elicits a range of emotional responses⋯. We believe that it is also important to acknowledge that, given the history of psychology’s inadequacies with diverse populations, multiculturalism is not an apoliticized theory. Much of the research done in the multicultural arena attempts to shift current thinking and institutional practices toward greater equality and recognition of diverse needs and perspectives. This agenda… implicates the subjective motivation of the researchers in the product.

Finally, much consensus exists over the necessity for more research and over the multitude of unanswered questions and issues. Ridley et al. (1994) indicate that cultural competency lacks theoretical grounding and adequate measures of the construct. Moreover, little research examines ethnic variations in response to treatment ( Mak et al. 2007 ). Despite the questions raised over cultural competency adaptations, the magnitude of mental health disparities in access to and quality of services for ethnic minority populations has spurred actions to address the problems.

WHAT HAS BEEN ACCOMPLISHED SO FAR?

Awareness of treatment disparities and the effects on mental health have stimulated the establishment of local, state, and federal guidelines for the delivery of culturally competent services. For example, the following federal agencies are among the many that have Websites that explain their cultural competency recommendations and guidelines:

• Administration on Aging, U.S. Department of Health & Human Services (HHS) ( http://www.aoa.dhhs.gov/prof/adddiv/cultural/addiv_cult.asp )
• Office of Minority Health, HHS ( http://www.omhrc.gov/templates/browse. aspx?lvl=1&lvlID=3 )
• Health Resources and Services Administration ( http://www.hrsa.gov/culturalcompetence/ )
• Substance Abuse and Mental Health Services Administration ( http://mentalhealth.samhsa.gov/dtac/CulturalCompetency.asp )

In terms of psychology organizations, counseling psychologists were among the first to extensively discuss and debate cultural competency issues through organizations such as the Association for Non-White Concerns in Personnel and Guidance in the 1970s and the Association for Multicultural Counseling and Development in the 1980s. Subsequently, many counseling psychologists through APA Division 17 (Counseling Psychology) and the National Institute for Multicultural Competence advocated for multicultural guidelines. Among clinical psychologists, APA Division 12 (Society of Clinical Psychology) established the section on the Clinical Psychology of Ethnic Minorities.

The APA has also had a history of involvement in ethnic, culture, and professional practice. The adoption of the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists had implications not only for mental health services but also for education, training, and research ( Am. Psychol. Assoc. 2003 ). These guidelines provided a context for service delivery: “Psychologists are encouraged to apply culturally appropriate skills in clinical and other applied psychological practices…” (p. 390). Cross-culturally sensitive practitioners are encouraged to develop skills and practices that are attuned to the unique worldviews and cultural backgrounds of clients by striving to incorporate understanding of a client’s ethnic, linguistic, racial, and cultural background into therapy” (p. 391).

Other professional organizations have issued statements, guidelines, or policies regarding cultural competency. For example, the American Psychiatric Association’s Steering Committee to Reduce Disparities in Access to Psychiatric Care (2004) developed an action plan to reduce disparities and to increase cultural awareness. Similarly, the National Association of Social Workers defined cultural competency as a set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals and enable the system, agency, or professionals to work effectively in multicultural situations. It then developed standards for cultural competence in social work practice ( Natl. Assoc. Social Workers 2007 ).

In the past two decades, cultural competency has been mandated to reduce mental health disparities; at the very least, cultural competency is recommended by various institutions, governmental bodies, and professional organizations. However, the mandates are rather hortatory or aspirational in nature because precise tactics and implementation strategies are unclear. Research is needed to gain knowledge about what works in cultural competency and how it works. It should be noted that most definitions of cultural competency do not include treatment outcomes as the major criteria for competence. This is surprising since it seems reasonable that if certain therapist skills or orientations are more culturally competent, these should be related to better treatment outcomes for ethnic minority clients (or at the minimum, equitable outcomes relative to those of mainstream clients). The proliferation of operational definitions of cultural competence may stem from the fact that these notions of competence have not been held empirically accountable to treatment outcomes—the gold standard ( U.S. Surgeon General 2001 ).

We indicate below the kinds of interventions that characterize cultural competency. We examine the research studies that have tested the effects of culturally competent interventions and discuss outcomes of these studies in the final section.

WHAT KINDS OF CULTURAL COMPETENCY INTERVENTIONS HAVE BEEN ATTEMPTED?

Considerable variation exists in the studies of culturally competent interventions. The interventions have ranged in terms of:

• Intervention approach. A narrow intervention is changing a specific feature of standard treatment practice such as conducting treatment in the ethnic language of the client. Broader interventions are those in which the general treatment approach is determined by the client’s ethnicity or in which many different features are based on cultural considerations (e.g., not only having a language match between client and therapist but also an ethnic and cultural match).
• Client problems and issues (e.g., rape prevention, treatment of schizophrenia, prevention of drug abuse, depression, and self-esteem).
• Ethnic/racial groups (African American, American Indian and Alaskan Natives, Asian Americans, and Hispanics). Most studies have been conducted on African Americans and Hispanics. Very few have included American Indians and Alaskan Natives. Some investigations involve more than one ethnic/racial group.
• Intervention type. Studies vary according to individual versus group interventions, treatment versus prevention, and use of standard treatments (e.g., cognitive behavioral treatment) versus specially developed interventions (e.g., cuento therapy for Puerto Ricans).

The studies also vary considerably on the type of research design (experimental, correlational, and archival), outcome measures used, the inclusion of control or alternative intervention groups, rigor in design, follow-up assessment, and sample size. In any event, we have classified the studies into certain categories for heuristic purposes only. We discuss culture competency in terms of method of delivery, content, and specialized interventions, which have been programmatically examined, such as cognitive behavioral treatments, storytelling interventions, and family therapies.

Method of Delivery

Method of delivery is intended to make the intervention more culturally consistent, increase credibility of the treatment or provider, or make the treatment understandable to ethnic minority clients. Delivery methods include intervention tactics that respond to the ethnic language of clients (e.g., translating materials or having bilingual therapists), varying the interpersonal style of the intervention (e.g., showing respeto or culturally appropriate respect with Hispanics), or providing a cultural context for interventions ( Andrés-Hyman et al. 2006 ). These changes share a common feature in that they involve generic applications; they can be implemented across most types of treatment (e.g., psychodynamic, behavioral, and cognitive-behavioral).

A minimum requirement of the intervention is that therapists must be able to communicate with clients in a manner that is culturally acceptable and appropriate. Clients who have limited English proficiency have difficulties entering, continuing, and benefiting from treatment ( Snowden et al. 2007 ) and appear to need culturally adapted interventions more than do clients who are acculturated and have greater English proficiency ( Sue et al. 1991 ). A number of investigations used therapists who speak the ethnic language of clients who have limited English proficiency. These studies explicitly report that treatment was conducted by therapists who were bilingual or who spoke the language of their clients. The languages have included Spanish (e.g., Armengol 1999 , Gallagher-Thompson et al. 2001 , Guinn & Vincent 2002 , Kopelowicz et al. 2003 , Martinez & Eddy 2005 ), Korean ( Shin 2004 , Shin & Lukens 2002 ), and Chinese ( Dai et al. 1999 ). Some studies attempted to see if ethnic match or a related form of match (e.g., cognitive match) between provider and client affected intervention outcomes or processes ( Campbell & Alexander 2002 , Flaskerud 1986 , Flaskerud & Hu 1994 , Mathews et al. 2002 , Sue et al. 1991 , Takeuchi et al. 1995 , Zane et al. 2005 ). Rather than examining specific therapist-client matches in language or other aspects, some studies have simply examined institutional resources (e.g., the extent to which agencies had therapists who could conduct treatment in the ethnic language of clients) and then correlated treatment outcomes for ethnic clients ( Campbell & Alexander 2002 , Flaskerud 1986 , Flaskerud & Hu 1994 , Gamst et al. 2003 , Lau & Zane 2000 , S. Sue et al. 1991 , Yeh et al. 1994 ). In all of the studies, it is difficult to ascertain the precise factors that account for client outcomes. As mentioned above, most investigations have included many different features of cultural competency, and language was only one of them. For example, having bilingual staff may provide not only language match but also cultural or ethnic match.

Besides language, other cultural competency adaptations were reflected in communication patterns. For instance, patterns of interactions common among less-acculturated Hispanic/Latinos were followed in Armengol’s (1999) study involving support group therapy.A formal mode of address was used if that was the stated preference of participants. Even when first names were preferred, the more formal personal pronoun form of “you” (i.e., “ usted ”) was employed. Participants also addressed the group facilitator by her professional title ( Doctora ), even when using her first name. The use of such practices is consistent with cultural values involving respeto and deference toward authority figures. These communication patterns have also been employed in other intervention strategies such as cognitive behavioral treatment and interpersonal psychotherapy ( Miranda et al. 2003a , Rossello et al. 2008 ). Although showing respect is desirable regardless of the client’s culture, knowledge of the culture determines how effectively that respect is shown and delivered.

In some intervention approaches, culturally consistent adaptations have involved the initiation of ceremonies that reflect cultural rituals such as a unity circle, a drum call, the pouring of libation to the ancestors, and a blessing for the day, which are African-based rituals ( Harvey & Hill 2004 ), and use of ethnic foods during intervention ( Longshore & Grills 2000 ).

Content refers to the discussion of, or dealing with, cultural patterns, immigration, minority status, racism, and cultural background experiences in the intervention. The introduction of content may serve to increase understandability and credibility of the intervention and to demonstrate the pertinence of the intervention to the real-life problems experienced by clients ( Ponterotto et al. 2006 ). Most interventions have both delivery and content elements. For example, in a culturally adapted management training intervention for Latino parents, Martinez & Eddy (2005) not only conducted training sessions in Spanish but also addressed culturally relevant immigration and acculturation issues. Similarly, relevant cultural content was included in a support group intervention for Hispanic traumatic brain injury survivors ( Armengol 1999 ) and in an educational intervention program for low-acculturated Latinas ( Guinn & Vincent 2002 ). The interventions included discussions of language, acculturation, spirituality, stressors inherent in the migratory experience, attitudes and beliefs about disability and health care, and support networks.

Interventions involving African American girls ( Belgrave 2002 , Belgrave et al. 2000 ), youths ( Cherry et al. 1998 , Harvey & Hill 2004 , Jackson-Gilfort et al. 2001 ), and adults ( Longshore & Grills 2000 ) have incorporated principles of spirituality, harmony, collective responsibility, oral tradition, holistic approach, experiences with prejudice and discrimination, racial socialization, and interpersonal/communal orientation that are often found in African American worldviews. In a rape prevention program that included many African Americans, Heppner et al. (1999) introduced culturally relevant content (e.g., including specific information about race-related rape myths and statistics on prevalence rates for both blacks and whites and having black and white guest speakers discuss their sexual violence experiences in a cultural context to increase the personal relevancy of the message). Robinson et al. (2003) studied the effects of school-based health center programs for African American students. All of the programs were intended to promote an African American atmosphere and theme. Features ranged from having school decorations and posters (representing Afrocentric perspectives and positive African American role models) to employing African American staff and tailoring services to be delivered in a culturally sensitive manner.

Culturally adapted content has also been used with other ethnic minority groups such as American Indians and Alaska Natives ( De Coteau et al. 2006 ). Fisher et al. (1996) used spiritual groups and cultural awareness training in a residential treatment program in Alaska. Schinke et al. (1988) provided biculturally relevant examples of verbal and nonverbal means of refusing substance use. For instance, leaders modeled how subjects could turn down offers of tobacco, alcohol, and drugs from peers without offending their American Indian and non-American Indian friends. While subjects practiced their communication skills, leaders offered coaching, feedback, and praise. Zane and colleagues (1998) report an example of a preventive intervention program for Asian Americans. The program was intended to prevent substance use and to increase the resiliency of high-risk Asian youths and their families. Group discussions and skill-building exercises for youths focused on Asian familial values, acculturation issues, and intergenerational communication. Parents participated in small-group workshops that also included topics involving cultural values, intergenerational communication, and family.

The studies indicate that cultural competency adaptations can range from simply providing ethnic language provisions to introducing multifaceted changes in intervention philosophy, delivery, and format. Some studies compared cultural adaptations to nointervention or no-adaptation control groups. Furthermore, components of cultural competency were not subjected to testing, so it is not possible to attribute possible positive effects of intervention to any particular component (e.g., determining whether treatment outcomes were caused by ethnic language translations or introduction of particular ethnic contents). Before we examine the outcome of cultural competency interventions, we discuss specific kinds of interventions, developed through more programmatic research, that have used cultural adaptations: storytelling, family interventions, and cognitive behavioral therapy.

Storytelling

Many Latinos answer questions by telling a story, thereby allowing the answer to emerge out of their narrative ( Comas-Díaz 2006 ). In order to improve the self-concept, emotional well-being, and adaptive behaviors of Puerto Rican children, researchers ( Costantino et al. 1986 ; Malgady et al. 1990a , b ) used cuentos (Puerto Rican folktales) or biographies of heroic persons. Folktales often convey a message or a moral to be emulated by others. The investigators incorporated themes such as social judgment, control of aggression, and delay of gratification within Puerto Rican American culture and experiences. By presenting culturally familiar characters of the same ethnicity as the children, they felt that the folktales would serve to motivate attentional processes; make it easier to identify with the beliefs, values, and behaviors portrayed in the adapted cuentos ; and model functional relationships with parental figures. Therapists, mothers, or group leaders read the cuentos bilingually, typically to children at risk for emotional or behavioral problems.

The research designs of the studies often compared adapted cuento intervention with original folktales (not adapted to U.S. experiences) to other forms of intervention (e.g., art/play therapy) or to a no-intervention control group. Children were randomly assigned to groups. Results across the various studies yielded favorable emotional and behavioral outcomes for the adapted cuento intervention compared with the other groups.

Szapocznik, Santisteban, and their colleagues ( Santisteban et al. 1997 , 2003 , 2006 ; Szapocznik et al. 1984 , 1986 , 1989 , 1990 , 2003 ) have systematically investigated the effects of specially designed, culturally adapted treatment interventions in families. Brief structural family therapy (BSFT) is an integration of structural and strategic theory and principles. BSFT was created because it was found to be adaptable and acceptable for work with Hispanic families. The investigators believe that the modality is especially suited to the needs of the targeted populations because it emerged out of experience in working with urban minority group families (particularly African American and Puerto Rican) that were disadvantaged in terms of social, cultural, educational, and political position in American society. Some components of the model are used with all families, and others are family specific and may be unique to certain cultural groups (i.e., immigration issues, racial prejudice issues).In BSFT, therapists take an active, directive, present-oriented leadership role that matches the expectations of the population.

Moreover, a structural family approach is consistent with Hispanics’ preference for clearly delineated hierarchies within the family. BSFT was able to directly address common acculturation-related stressors, such as acculturation differences and intergenerational conflicts between children and their parents. Research designs for the studies of BSFT often included randomized control trials. In general, BSFT was found to be as good as or (typically) superior to control conditions in reducing parent and youth reports of problems associated with conduct, family functioning, and treatment engagement.

Cognitive Behavioral Therapy

A number of studies have examined whether culturally adapted forms of cognitive behavioral therapy (CBT) are more effective than are nonadapted forms of CBT, whether culturally adapted treatment demonstrates positive outcomes, or whether certain components of CBT are more helpful than others ( Jackson et al. 2006 , Shen et al. 2006 ). These studies are important because CBT is effective for many different problems (e.g., anxiety and depression) and for different ethnic populations. Furthermore, because CBT is often delivered with a fixed format or manualized script, it can readily incorporate cultural adaptations and be tested. For example, Kohn and colleagues (2002) examined the degree to which a manualized CBT intervention could be adapted in a culturally sensitive manner in treating depressed low-income African American women experiencing multiple stressors. The adaptations included changes in the language used to describe cognitive-behavioral techniques and inclusion of culturally specific content (e.g., African American family issues) in order to better situate the intervention in an African American context. Compared with a nonadaptedCBT intervention group, womenin the adaptedCBT group exhibited a larger drop in depression. De Coteau et al. (2006) have offered general guidelines for modifying manualized treatments that are particularly applicable to Native Americans living on reservations or in rural tribal communities.

Miranda and her colleagues (2003a) have studied whether cultural adaptations to CBT improve the outcomes of treatment for Hispanics. In randomized trials, the adapted form of CBT consisted of having bilingual and bicultural providers, translating all materials into Spanish, training staff to show respeto and simpatia to patients, and allowing for somewhat warmer, more personalized interactions than are typical for English-speaking patients. These adaptations were considered to be culturally responsive. The patients who received the adapted CBT had lower dropout rates than those who received CBT alone. There was indication that the effects of adapted CBT were stronger among those whose first language was Spanish rather than English in terms of greater improvement in symptoms and functioning.

Miranda et al. (2003b) have also shown that quality improvement interventions for depressed primary care patients can improve treatment outcomes for ethnic minority groups. Because ethnic minority clients often receive poorer quality of services than do white clients ( U.S. Surgeon General 2001 ), the investigators wanted to study the effects of quality improvements to care. The culturally adapted improvements included the availability of materials in English and Spanish. Hispanic and African American providers were included in videotaped materials for patients. In addition, providers were given training materials that dealt with cultural beliefs and ways of overcoming barriers to care for Latino and African American patients. The quality improvement interventions resulted in beneficial outcomes. However, because the study included general improvements as well as culturally relevant interventions, it was not possible to determine what factors in the interventions caused the favorable outcomes.

Rossello & Bernal (1999) found that cultural adaptations to CBT and interpersonal psychotherapy (IPT) were more effective than a wait-list control group in reducing depression among Puerto Rican youths. Rossello et al. (2008) maintain that certain treatment approaches, such as CBT and IPT, may intrinsically appeal to the cultural orientation of Latinos. CBT has ( a ) a didactic orientation that provides structure to treatment and education about the therapeutic process; ( b ) a classroom format that reduces the stigma of psychotherapy; ( c ) a match with client expectations of receiving a directive and active intervention from the provider; ( d ) an orientation focused on the present and on problem solving; and ( e ) concrete solutions and techniques to be used when facing problems. On the other hand, IPT focuses largely on the present interpersonal conflicts that are pertinent to Latino values of familismo (family) and personalismo (personal considerations). The congruence of CBT and IPT with Latino values made it easier for the investigators to adapt them for use with Puerto Rican adolescents. The adolescents were randomly assigned to CBT (individual or group treatment) or IPT (individual or group treatment). Results revealed that all groups demonstrated decreases in depressive symptoms with CBT that were superior to IPT.

Other studies have introduced cultural adaptations in cognitive behavioral training. Gallagher-Thompson et al. (2001) designed a culturally sensitive eight-week class that taught specific cognitive and behavioral skills for coping with the frustrations associated with caregiving. Hispanic caregivers of dementia victims were assigned to the training class or to a waitlist control group. At the end of the intervention, trained caregivers reported significantly fewer depressive symptoms than did those in the control group. Hinton et al. (2005) has also used CBT to treat Cambodian refugees by using culturally appropriate visualization tasks.

Findings from the CBT studies provide consistent indication that cultural competency interventions are effective, and two of the studies ( Kohn et al. 2002 , Miranda et al. 2003a ) found that cultural competency adaptations to CBT were superior to nonadapted CBT.

IS TREATMENT GENERALLY EFFECTIVE WITH ETHNIC MINORITY POPULATIONS?

As mentioned above, ethnic and racial disparities exist in treatment access and quality. Does this mean that treatment is not effective with ethnic minority populations or that ethnic clients should not seek treatment for mental health problems? Despite the disparities, treatment is needed and can be helpful for all populations ( President’s New Freedom Commission 2003 , U.S. Surgeon General 2001 ). Ethnic minority populations need access to the best forms of treatment. The questions to be answered include what are the best forms of treatment for ethnic minority populations and whether cultural competency interventions add to positive treatment outcomes.

In the mental health field, widespread attempts have been made to define the best forms of treatment. Outcomes of mental health care are evaluated through two types of research, efficacy and effectiveness studies ( Miranda et al. 2005 ). Efficacy studies, or randomized, controlled trials, are valuable in determining the treatment factors that determine outcomes. They are designed to maximize internal validity and are rigorously conducted, often in strictly controlled settings. Effectiveness research is typically conducted in more real-life situations and may not achieve the rigor and controls found in efficacy studies. It often provides greater external validity than internal validity compared to efficacy studies. Efficacy and effectiveness research is used to guide treatment recommendations. The use of research to establish best practices has resulted in the designation of evidence-based practices (EBPs) and empirically supported treatments (ESTs). EBPs are those psychotherapeutic practices that have demonstrated value through either effectiveness or efficacy research. ESTs are certain types of EBPs that have been shown through rigorous efficacy research to result in positive outcomes. However, little research has been conducted on the value of EBPs and ESTs for ethnic minority populations ( Constantine et al. 2008 ). As late as 1996, Chambless and colleagues (1996) could not find even one EST study that analyzed ethnicity as a variable. More recently, Mak et al. (2007) conducted a review of clinical trial studies. They found that most of the studies reported gender information, and gender representation was balanced across studies. However, less than half of the studies provided complete racial/ethnic information with respect to their samples. Except for whites and African Americans, all racial/ethnic groups were underrepresented, and less than half of the studies had potential for subgroup analyses by gender and race/ethnicity ( Mak et al. 2007 ). Given the paucity of research, the external validity of EBPs has not been clearly established ( Whaley & Davis 2007 ). The lack of research has led many to conclude that the answers are still unclear as to whether EBPs and ESTs are effective with these populations and the conditions under which such treatments are beneficial ( Castro et al. 2004 , Sue & Zane 2006 ).

Studies of treatment and preventive intervention effects for ethnic minorities were reviewed by Miranda et al. (2005) . In general, their review concluded that EBPs were effective with different ethnic minority groups and ethnic minority children and adults for a wide range of mental disorders and problem behaviors (e.g., depression, anxiety, and family problems). A meta-analysis of evidence-based treatments for ethnic minority youths was conducted by Huey & Polo (2008) . They found that these interventions produced positive overall treatment effects of medium magnitude. However, the investigators raised the possibility that the EBPs and ESTs may sometimes have included cultural adaptations such as performing the interventions in the cultural context of the client, using the client’s ethnic language, or integrating cultural elements. We do not know the extent to which research studies use culturally adapted elements but fail to report them. Given the preponderance of evidence that EBPs and ESTs are often effective, are culturally competent adaptations needed?

DO CULTURAL COMPETENCY ADAPTATIONS DEMONSTRATE POSITIVE AND INCREMENTAL EFFECTS ON TREATMENT?

What does research reveal about the effects of cultural competency interventions? Two metaanalyses are pertinent to this question. Griner & Smith (2006) directly examined the effects of cultural competency interventions. Huey & Polo (2008) confined their meta-analysis to ethnic minority youths and indirectly addressed the question after examining the outcomes of evidence-based treatments (and not necessarily cultural-competency studies) for ethnic minority youths.

Because Griner & Smith (2006) is the only meta-analysis to date that has examined the effects of culturally competent interventions, we want to elaborate on its findings. Their metaanalysis revealed that there are controlled, experimental studies of cultural competency. For more than two decades, such studies have appeared, albeit few in number and varying in methodological soundness. Studies included in their meta-analysis largely involved the comparison of culturally adapted mental health interventions to traditional mental health interventions. Griner & Smith (2006) identified 76 studies. Their analysis revealed a moderate effect size for culturally competent interventions [the random effects weighted average effect size was d = 0.45 (SE = 0.04, p < 0.0001), with a 95% confidence interval of d = 0.36 to d = 0.53. The data consisted of 72 nonzero effect sizes, of which 68 (94%) were positive and 4 (6%) were negative. Effect sizes ranged from d = −0.48 to d = 2.7].

Importantly, Griner & Smith (2006) attempted to control for or clarify the effects of other possible confounding variables.

• Publication bias (e.g., studies with statistically significant results are more likely to be published than are studies with statistically nonsignificant results). Their analysis indicated that publication bias does not appear to be a substantial threat to the results obtained in the meta-analysis.
• Participant characteristics (i.e., participant age, clinical status, gender, ethnicity, and level of acculturation). Older individuals had higher effect sizes than younger persons. In general, ethnicity of the client did not moderate the results obtained. In addition, for Hispanic clients, ethnicity tended to interact with acculturation in that low levels of acculturation appeared to profit greatly from culturally competent interventions.
• Research procedures (e.g., experimental versus single-group designs). Overall results were not altered by studies that varied as to the research design, inclusion of control groups, or nature of the control group.
• Type of cultural adaptations. Some studies involved individual therapy whereas many others involved group interventions or a combination of the two. The format of the intervention did not moderate the overall results, nor did the duration of interventions. However, studies that were focused on one ethnic/racial population yielded higher effect sizes than those in which mixed racial populations were included. Studies in which there were no reports of attempting to match clients and therapists based on ethnicity had average effect sizes that were higher than those of studies in which ethnic matching was generally attempted (but not consistently conducted). Studies in which the client was matched with a therapist based on language (if other than English) had outcomes that were twice as effective as were studies that did not match language.

The contribution of Griner & Smith (2006) is highly significant. Not only do they provide evidence for the value of cultural competency, but they also examine possible confounding effects associated with cultural competency. As recognized by the investigators, their meta-analysis was the first one to be applied to cultural competency studies. Therefore, it included all research reports available, regardless of quality and rigor. Indeed, the reports varied considerably in terms of population studied (problems/disorders, age groups, ethnicity, etc.), methodology (random versus nonrandom assignment to treatment/control conditions, follow-up design, measures used, etc.), and type of treatment (e.g., from English translations of materials to contextual changes in the setting of treatment). Given the diversity of the studies, cultural competency has positive effects on treatment outcomes even though the precise factors that account for the effects cannot be easily specified at this time.

Three positions, ranging in favorability to cultural competency adaptations, have been articulated from reviews. First, Griner & Smith (2006) conclude in their meta-analysis that cultural competency interventions have a moderate positive effect. Second, Miranda et al. (2005) take a more cautious position because of the lack of adequate tests for cultural competency effects. Nevertheless, they state, “In the absence of efficacy studies, the combined used of protocols or guidelines that consider culture and context with evidence-based care is likely to facilitate engagement in treatment and probably to enhance outcomes.” Third, in contrast to the conclusions of Smith & Griner (2006) , Huey&Polo (2008) state in their meta-analysis:

… there is no compelling evidence as yet that these adaptations actually promote better clinical outcomes for ethnic minority youth. Overemphasizing the use of conceptually appealing but untested cultural modifications could inadvertently lead to inefficiencies in the conduct of treatment with ethnic minorities.

Thus, the most discrepant conclusions are derived from the two meta-analyses. The differing conclusions may simply be the result of the nature of the studies. Griner & Smith (2006) included interventions with adults and children, whereas Huey & Polo (2008) focused on children and youths. Interestingly, little overlap exists in the cultural competency adaptation studies that were included in their respective meta-analyses, even when one takes into account the dissimilar time periods for the reviews. This may reflect different inclusion/exclusion criteria used in the two metaanalyses. In addition, differences may exist in how the studies are interpreted. The relatively few rigorous studies that directly compare culturally adapted interventions with nonculturally adapted interventions also add to the problems in trying to draw conclusions. Two studies ( Kohn et al. 2002 , Miranda et al. 2003a ) comparing culturally adapted CBT with nonculturally adapted CBT demonstrated the superiority of the cultural interventions. Finally, it is possible that interventions not considered culturally adapted may contain cultural features. As mentioned above, treatments may include discussions of cultural content even though they are not intended to be culturally adapted interventions. Or the treatments (e.g., CBT) may be inherently consistent with one’s cultural orientation, as argued by Rossello et al. (2008) . In either case, the manipulation of “not adapted” may be contaminated.

FINAL THOUGHTS

• The preponderance of evidence shows that culturally adapted interventions provide benefit to intervention outcomes. This added value is more apparent in the research on adults than on children or youths. The additive effect of culturally adapted interventions is consistent with research examining the extent to which an intervention is implemented according to its original design, namely, its fidelity or is adapted. Blakely et al. (1987) found that adaptations involving adding certain features to an intervention were more effective than were adaptations involving replacing a component of the intervention.
• Culturally competent interventions cover a whole range of activities (e.g., language match, discussions of cultural issues, and delivery of treatment in a culturally consistent manner).
• Given the relatively few empirical studies of cultural competency, more research is needed, especially randomized clinical trials and “unpackaging” research that examines which cultural adaptations are effective.
• Therapist, client, and intervention factors probably influence who is most likely to benefit from specific culturally adapted interventions. For example, cultural competency methods are probably more important with unacculturated than with acculturated ethnic minority clients. Individual differences as well as ethnic and cultural differences should be considered in the nature of the intervention delivery styles and content.
• Little consensus currently exists as to when to use cultural interventions. Some believe that all interventions should be culturally competent in that therapists need to have appropriate cultural awareness, knowledge, and skills to work with clients. The kind-of-person model for cultural competency argues for cultural competency as an integral part of any treatment. For other multiculturalists, cultural interventions should be introduced under certain conditions. Leong & Lee (2006) have developed a model intended to identify cultural gaps in particular treatments and then to adopt adaptations that address the gaps. Lau (2006) maintains that culturally adapted treatments should be judiciously applied and are warranted ( a ) if evidence exists that a particular clinical problem encountered by a client emerges within a distinct set of risk and resilience factors in a given ethnic community or ( b ) if clients from a given ethnic community respond poorly to certain EBT approaches. In other words, cultural adaptations to EBT should be used if the problems encountered by individuals are influenced by membership in a particular (e.g., ethnic minority) community or if members of that community respond poorly to a standard EBT treatment. Similarly, Zavfert (2008) proposes that an ideographic approach should be taken that would rely on assessment of key cultural factors that are empirically determined to be most relevant to development and maintenance of a particular problem. When specifying culturally competent adaptations, the particular cultural factors affecting the client are considered as well as individual differences in acculturation, experiential background, type of disorder, etc.
• A major disconnect appears to exist between cultural competency guidelines or recommendations and psychotherapy research examining cultural issues in treatment. The former has tended to focus on characteristics, values, attitudes, and skills on the part of the therapist that can minimize the social and cultural distance between care provider and client, whereas the latter has tended to examine changes in treatment procedures and content that more adequately address the cultural experiences of ethnic minority clients. This difference in emphasis on therapist adaptation as opposed to treatment adaptation may partially account for the slow progress made in developing culturally competent mental health care. Norcross & Goldfried (1992) found that therapist and relationship factors accounted for 30% of the improvement in psychotherapy patients, whereas client, family, and other environmental factors accounted for 40%. Specific treatment techniques when combined with the expectancy factors commonly associated with placebo effects accounted for the other 30% of improvement. This research strongly suggests that both therapist and treatment adaptations warrant attention in cultural competency studies. Clearly, research is needed that investigates how these two types of adaptations interact and the separate and combined effects they have on treatment outcomes. For example, in most treatment adaptation studies, the level of therapist skill related to cultural competency is unknown or not assessed. On the other hand, when therapist cultural competency skills are examined, it is unclear if therapists who are deemed culturally competent also may be using certain cultural adaptations in their treatment practices. At the very least, these types of adaptations must be examined or controlled for if research on cultural competence is to proceed in a more informed manner.
• Finally, the evaluation of the extent to which therapists and interventions effectively address cultural issues is situated in the complex interplay of processes that account for behavior and attitudinal change in psychotherapy. We have noted that theoretical and methodological inadequacies in psychotherapy research have combined to perpetuate imprecise models of change. When it is unclear how people change in psychotherapy and what they have learned in this process, the task of identifying those aspects of treatment that would make it culturally responsive or competent becomes even more difficult ( Zane & Sue 1991 ).

SUMMARY POINTS

• There is a growing movement to make services more culturally competent.
• Cultural competency has been defined in many different ways, and it has provoked considerable controversy over its assumptions, effects, and necessity.
• Cultural competency interventions have varied considerably, ranging from encompassing an entire treatment program to selected adaptations to existing treatment procedures.
• Research on cultural competency has increased over time, although research designs have differed in the degree of rigor.
• The available evidence indicates that cultural competency in psychological interventions and treatments is valuable and needed.

FUTURE ISSUES

Further research is needed to answer the following questions.

• Is cultural competency better conceptualized as a concrete skill that can be learned by anyone or as a complex process that depends on social interactions?
• Can a theoretical model be devised that explains cultural competency and why it works?
• Why do research findings on the effects of culturally competent interventions show so much variability?
• How can the multicultural guidelines adopted by the American Psychological Association be implemented in research, practice, and training?
• Can universally beneficial treatment strategies (that apply to everyone) versus beneficial culture-specific interventions (that apply to specific populations) be identified?

ACKNOWLEDGMENT

This study was supported in part by the Asian American Center on Disparities Research (National Institute of Mental Health grant 1P50MH073511-01A2).

The Annual Review of Psychology is online at psych.annualreviews.org

DISCLOSURE STATEMENT

The authors are not aware of any biases that might be perceived as affecting the objectivity of this review.

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Revolutionizing the Study of Mental Disorders

March 27, 2024 • Feature Story • 75th Anniversary

At a Glance:

• The Research Domain Criteria framework (RDoC) was created in 2010 by the National Institute of Mental Health.
• The framework encourages researchers to examine functional processes that are implemented by the brain on a continuum from normal to abnormal.
• This way of researching mental disorders can help overcome inherent limitations in using all-or-nothing diagnostic systems for research.
• Researchers worldwide have taken up the principles of RDoC.
• The framework continues to evolve and update as new information becomes available.

President George H. W. Bush proclaimed  the 1990s “ The Decade of the Brain  ,” urging the National Institutes of Health, the National Institute of Mental Health (NIMH), and others to raise awareness about the benefits of brain research.

“Over the years, our understanding of the brain—how it works, what goes wrong when it is injured or diseased—has increased dramatically. However, we still have much more to learn,” read the president’s proclamation. “The need for continued study of the brain is compelling: millions of Americans are affected each year by disorders of the brain…Today, these individuals and their families are justifiably hopeful, for a new era of discovery is dawning in brain research.”

Still, despite the explosion of new techniques and tools for studying the brain, such as functional magnetic resonance imaging (fMRI), many mental health researchers were growing frustrated that their field was not progressing as quickly as they had hoped.

For decades, researchers have studied mental disorders using diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (DSM)—a handbook that lists the symptoms of mental disorders and the criteria for diagnosing a person with a disorder. But, among many researchers, suspicion was growing that the system used to diagnose mental disorders may not be the best way to study them.

“There are many benefits to using the DSM in medical settings—it provides reliability and ease of diagnosis. It also provides a clear-cut diagnosis for patients, which can be necessary to request insurance-based coverage of healthcare or job- or school-based accommodations,” said Bruce Cuthbert, Ph.D., who headed the workgroup that developed NIMH’s Research Domain Criteria Initiative. “However, when used in research, this approach is not always ideal.”

Researchers would often test people with a specific diagnosed DSM disorder against those with a different disorder or with no disorder and see how the groups differed. However, different mental disorders can have similar symptoms, and people can be diagnosed with several different disorders simultaneously. In addition, a diagnosis using the DSM is all or none—patients either qualify for the disorder based on their number of symptoms, or they don’t. This black-and-white approach means there may be people who experience symptoms of a mental disorder but just miss the cutoff for diagnosis.

Dr. Cuthbert, who is now the senior member of the RDoC Unit which orchestrates RDoC work, stated that “Diagnostic systems are based on clinical signs and symptoms, but signs and symptoms can’t really tell us much about what is going on in the brain or the underlying causes of a disorder. With modern neuroscience, we were seeing that information on genetic, pathophysiological, and psychological causes of mental disorders did not line up well with the current diagnostic disorder categories, suggesting that there were central processes that relate to mental disorders that were not being reflected in DMS-based research.”

Road to evolution

Concerned about the limits of using the DSM for research, Dr. Cuthbert, a professor of clinical psychology at the University of Minnesota at the time, approached Dr. Thomas Insel (then NIMH director) during a conference in the autumn of 2008. Dr. Cuthbert recalled saying, “I think it’s really important that we start looking at dimensions of functions related to mental disorders such as fear, working memory, and reward systems because we know that these dimensions cut across various disorders. I think NIMH really needs to think about mental disorders in this new way.”

Dr. Cuthbert didn’t know it then, but he was suggesting something similar to ideas that NIMH was considering. Just months earlier, Dr. Insel had spearheaded the inclusion of a goal in NIMH’s 2008 Strategic Plan for Research to “develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.”

Unaware of the new strategic goal, Dr. Cuthbert was surprised when Dr. Insel's senior advisor, Marlene Guzman, called a few weeks later to ask if he’d be interested in taking a sabbatical to help lead this new effort. Dr. Cuthbert soon transitioned into a full-time NIMH employee, joining the Institute at an exciting time to lead the development of what became known as the Research Domain Criteria (RDoC) Framework. The effort began in 2009 with the creation of an internal working group of interdisciplinary NIMH staff who identified core functional areas that could be used as examples of what research using this new conceptual framework looked like.

The workgroup members conceived a bold change in how investigators studied mental disorders.

“We wanted researchers to transition from looking at mental disorders as all or none diagnoses based on groups of symptoms. Instead, we wanted to encourage researchers to understand how basic core functions of the brain—like fear processing and reward processing—work at a biological and behavioral level and how these core functions contribute to mental disorders,” said Dr. Cuthbert.

This approach would incorporate biological and behavioral measures of mental disorders and examine processes that cut across and apply to all mental disorders. From Dr. Cuthbert’s standpoint, this could help remedy some of the frustrations mental health researchers were experiencing.

Around the same time the workgroup was sharing its plans and organizing the first steps, Sarah Morris, Ph.D., was a researcher focusing on schizophrenia at the University of Maryland School of Medicine in Baltimore. When she first read these papers, she wondered what this new approach would mean for her research, her grants, and her lab.

She also remembered feeling that this new approach reflected what she was seeing in her data.

“When I grouped my participants by those with and without schizophrenia, there was a lot of overlap, and there was a lot of variability across the board, and so it felt like RDoC provided the pathway forward to dissect that and sort it out,” said Dr. Morris.

Later that year, Dr. Morris joined NIMH and the RDoC workgroup, saying, “I was bumping up against a wall every day in my own work and in the data in front of me. And the idea that someone would give the field permission to try something new—that was super exciting.”

The five original RDoC domains of functioning were introduced to the broader scientific community in a series of articles published in 2010  .

To establish the new framework, the RDoC workgroup (including Drs. Cuthbert and Morris) began a series of workshops in 2011 to collect feedback from experts in various areas from the larger scientific community. Five workshops were held over the next two years, each with a different broad domain of functioning based upon prior basic behavioral neuroscience. The five domains were called:

• Negative valence (which included processes related to things like fear, threat, and loss)
• Positive valence (which included processes related to working for rewards and appreciating rewards)
• Cognitive processes
• Social processes
• Arousal and regulation processes (including arousal systems for the body and sleep).

At each workshop, experts defined several specific functions, termed constructs, that fell within the domain of interest. For instance, constructs in the cognitive processes domain included attention, memory, cognitive control, and others.

The result of these feedback sessions was a framework that described mental disorders as the interaction between different functional processes—processes that could occur on a continuum from normal to abnormal. Researchers could measure these functional processes in a variety of complementary ways—for example, by looking at genes associated with these processes, the brain circuits that implement these processes, tests or observations of behaviors that represent these functional processes, and what patients report about their concerns. Also included in the framework was an understanding that functional processes associated with mental disorders are impacted and altered by the environment and a person’s developmental stage.

Preserving momentum

Over time, the Framework continued evolving and adapting to the changing science. In 2018, a sixth functional area called sensorimotor processes was added to the Framework, and in 2019, a workshop was held to better incorporate developmental and environmental processes into the framework.;

Since its creation, the use of RDoC principles in mental health research has spread across the U.S. and the rest of the world. For example, the Psychiatric Ratings using Intermediate Stratified Markers project (PRISM)   , which receives funding from the European Union’s Innovative Medicines Initiative, is seeking to link biological markers of social withdrawal with clinical diagnoses using RDoC-style principles. Similarly, the Roadmap for Mental Health Research in Europe (ROAMER)  project by the European Commission sought to integrate mental health research across Europe using principles similar to those in the RDoC Framework.;

Dr. Morris, who has acceded to the Head of the RDoC Unit, commented: “The fact that investigators and science funders outside the United States are also pursuing similar approaches gives me confidence that we’ve been on the right pathway. I just think that this has got to be how nature works and that we are in better alignment with the basic fundamental processes that are of interest to understanding mental disorders.”

The RDoC framework will continue to adapt and change with emerging science to remain relevant as a resource for researchers now and in the future. For instance, NIMH continues to work toward the development and optimization of tools to assess RDoC constructs and supports data-driven efforts to measure function within and across domains.

“For the millions of people impacted by mental disorders, research means hope. The RDoC framework helps us study mental disorders in a different way and has already driven considerable change in the field over the past decade,” said Joshua A. Gordon, M.D., Ph.D., director of NIMH. “We hope this and other innovative approaches will continue to accelerate research progress, paving the way for prevention, recovery, and cure.”

Publications

Cuthbert, B. N., & Insel, T. R. (2013). Toward the future of psychiatric diagnosis: The seven pillars of RDoC. BMC Medicine , 11 , 126. https://doi.org/10.1186/1741-7015-11-126  

Cuthbert B. N. (2014). Translating intermediate phenotypes to psychopathology: The NIMH Research Domain Criteria. Psychophysiology , 51 (12), 1205–1206. https://doi.org/10.1111/psyp.12342  

Cuthbert, B., & Insel, T. (2010). The data of diagnosis: New approaches to psychiatric classification. Psychiatry , 73 (4), 311–314. https://doi.org/10.1521/psyc.2010.73.4.311  

Cuthbert, B. N., & Kozak, M. J. (2013). Constructing constructs for psychopathology: The NIMH research domain criteria. Journal of Abnormal Psychology , 122 (3), 928–937. https://doi.org/10.1037/a0034028  

Garvey, M. A., & Cuthbert, B. N. (2017). Developing a motor systems domain for the NIMH RDoC program.  Schizophrenia Bulletin , 43 (5), 935–936. https://doi.org/10.1093/schbul/sbx095  

Kozak, M. J., & Cuthbert, B. N. (2016). The NIMH Research Domain Criteria initiative: Background, issues, and pragmatics. Psychophysiology , 53 (3), 286–297. https://doi.org/10.1111/psyp.12518  

Morris, S. E., & Cuthbert, B. N. (2012). Research Domain Criteria: Cognitive systems, neural circuits, and dimensions of behavior. Dialogues in Clinical Neuroscience , 14 (1), 29–37. https://doi.org/10.31887/DCNS.2012.14.1/smorris  

Sanislow, C. A., Pine, D. S., Quinn, K. J., Kozak, M. J., Garvey, M. A., Heinssen, R. K., Wang, P. S., & Cuthbert, B. N. (2010). Developing constructs for psychopathology research: Research domain criteria. Journal of Abnormal Psychology , 119 (4), 631–639. https://doi.org/10.1037/a0020909  

• Presidential Proclamation 6158 (The Decade of the Brain) 
• Research Domain Criteria Initiative website
• Psychiatric Ratings using Intermediate Stratified Markers (PRISM)  

Prairie voles display signs of human-like depression

Critters can be used to better understand depression.

Psychology researchers at The University of Texas at El Paso are making progress towards understanding the biological underpinnings of depression, a leading cause of disability that affects approximately 280 million people around the world.

In a study published this April in the Journal of Affective Disorders , UTEP psychologist Sergio Iñiguez, Ph.D., and his co-authors make the case that prairie voles, small rodents that are found throughout the central United States and Canada, can be effectively used as animal models to further the study of clinical depression.

"The findings of this investigation are important because we show, for the first time, that prairie voles display some of the core symptoms of depression after chronic stress exposure -- just like humans," Iñiguez said. "This is exciting because we can now use this animal model to potentially uncover the biological factors that underlie illnesses like depression and anxiety."

The UTEP study focuses on the impact of "bullying" on voles' behavioral patterns. Researchers observed what happened when individual male voles were bullied by more aggressive males over the course of ten days, inducing what Iñiguez refers to as "social defeat stress."

Iñiguez explained that that the voles who were bullied exhibited changes in body weight, performed worse on spatial memory tests and were less sociable with other voles compared to those who were not bullied. Where voles generally show a preference for sugar water, the bullied voles showed no preference when given a choice between regular water and sugar water, a pattern known as anhedonia, or loss of pleasure in regular activities, Iñiguez said.

Iñiguez and his fellow researchers concluded that "social defeat" activated the voles' stress response and became a risk factor for symptoms that mirrored those of depression in humans.

Iñiguez, a professor in the Department of Psychology at UTEP who studies behavioral neuroscience, said that while depression has certain defining characteristics -- such as sadness, lack of pleasure in normal activities, and disruption in sleep and eating patterns -- researchers don't yet have a full picture of what causes it.

"We have some information about the many factors that contribute to depression, but the ethical implications of doing neurobiological research in humans make it difficult to pinpoint the biology behind this debilitating condition," Iñiguez said.

Rats and mice are often used in psychology studies, but prairie voles share several unique characteristics with humans that make them better candidates for research, such as having monogamous relationships, raising vole pups in pairs, and even taking on parental roles for orphaned pups.

Psychology doctoral student Minerva Rodriguez is the lead author of the study.

"These unique and specialanimals have opened doors to understanding aspects of depression we simply could not with mice and rats," Rodriguez said. "Their distinct social behaviors provide fresh research avenues, demonstrating the prairie vole's immense value as a model for delving into the neurobiology of social stress-induced depression."

Future studies will examine how the voles rebound from depression-like experiences and how they respond to antidepressant medications like Prozac or ketamine.

The project is funded by a grant from the National Institutes of Health.

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Story Source:

Materials provided by University of Texas at El Paso . Note: Content may be edited for style and length.

Journal Reference :

• Minerva Rodriguez, Anapaula Themann, Israel Garcia-Carachure, Omar Lira, Alfred J. Robison, Bruce S. Cushing, Sergio D. Iñiguez. Chronic social defeat stress in prairie voles (Microtus ochrogaster): A preclinical model for the study of depression-related phenotypes . Journal of Affective Disorders , 2024; 351: 833 DOI: 10.1016/j.jad.2024.02.001

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If you've heard of or read about mindfulness meditation — also known as mindfulness — you might be curious about how to practice it. Find out how to do mindfulness exercises and how they might benefit you.

What is mindfulness?

Mindfulness is a type of meditation in which you focus on being intensely aware of what you're sensing and feeling in the moment, without interpretation or judgment. Practicing mindfulness involves breathing methods, guided imagery, and other practices to relax the body and mind and help reduce stress.

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What are some examples of mindfulness exercises?

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• Body scan meditation. Lie on your back with your legs extended and arms at your sides, palms facing up. Focus your attention slowly and deliberately on each part of your body, in order, from toe to head or head to toe. Be aware of any sensations, emotions or thoughts associated with each part of your body.
• Sitting meditation. Sit comfortably with your back straight, feet flat on the floor and hands in your lap. Breathing through your nose, focus on your breath moving in and out of your body. If physical sensations or thoughts interrupt your meditation, note the experience and then return your focus to your breath.
• Walking meditation. Find a quiet place 10 to 20 feet in length, and begin to walk slowly. Focus on the experience of walking, being aware of the sensations of standing and the subtle movements that keep your balance. When you reach the end of your path, turn and continue walking, maintaining awareness of your sensations.

When and how often should I practice mindfulness exercises?

It depends on what kind of mindfulness exercise you plan to do.

Simple mindfulness exercises can be practiced anywhere and anytime. Research indicates that engaging your senses outdoors is especially beneficial.

For more structured mindfulness exercises, such as body scan meditation or sitting meditation, you'll need to set aside time when you can be in a quiet place without distractions or interruptions. You might choose to practice this type of exercise early in the morning before you begin your daily routine.

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• Bystritsky A. Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions. https://uptodate.com/contents/search. Accessed June 14, 2018.
• Seaward BL. Meditation and mindfulness. In: Managing Stress: Principles and Strategies for Health and Well-being. 9th ed. Burlington, Mass.: Jones & Bartlett Learning; 2018.
• Shapiro SL, et al. The Art and Science of Mindfulness: Integrating Mindfulness into Psychology and the Helping Professions. 2nd ed. Washington, D.C.: American Psychological Association; 2017.
• Lymeus F, et al. Building mindfulness bottom-up: Meditation in natural settings supports open monitoring and attention restoration. Consciousness and Cognition. 2018;59:40.
• Blanck P, et al. Effects of mindfulness exercises as stand-alone interventions on symptoms of anxiety and depression: Systematic review and meta-analysis. Behaviour Research and Therapy. 2018;102:25.
• AskMayoExpert. Meditation. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2018.
• Khoury B, et al. Mindfulness-based stress reduction for healthy individuals: A meta-analysis. Journal of Psychosomatic Research. 2015;78:519.
• Practice mindfulness and relaxation. Springboard Beyond Cancer. https://survivorship.cancer.gov/springboard/stress-mood/practice-mindfulness. Accessed June 14, 2018.

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