Adapting Evidence-based Practices for Under-resourced Populations: SAMHSA Features AFFIRM
This guide focuses on research supporting adaptations of evidence-based practices (EBPs) for under-resourced populations. Adaptations involve tailoring care, programs, and services to the cultural, social, gender, and demographic contexts of the people served to yield positive outcomes.
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Abstract
Tailoring care, programs, and services to the cultural, social, gender, and other socio-demographic contexts of individuals served yields positive outcomes. Communities and individuals benefit when they receive behavioural health services that are clinically proven effective, equitable, and culturally appropriate. This guide focuses on the process of adapting evidence-based practices (EBPs) for under-resourced populations who experience obstacles in obtaining healthcare services because of their socio-demographic characteristics, and the research supporting such adaptations. The guide provides examples of research on adapted EBPs for mental health and substance use disorders for clients with a wide range of demographic characteristics. The guide provides considerations and strategies for community leaders and advocates, behavioral health practitioners, administrators, and organizational decision-makers.
Examples of Cultural Adaptations of Evidence-Based Practices
Highlighting three examples of organizations developing and implementing adapted evidence-based practices (EBPs) for under-resourced populations in their communities. The three examples differ from one another in terms of the context, EBP, and adaptations to the EBP.
• The first example, Youth AFFIRM, describes the adaptation and implementation of cognitive behavioral therapy (CBT) for Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ+) young people. The creators found a shortage of evidence-based treatment interventions created for and tested among LGBTQ+ young people with mental health conditions and identified components of standard CBT that could be adapted to resonate more deeply with individuals they hoped to serve.
Chapter 2 describes a process of cultural adaptation, which is not always linear. Programs typically begin with community engagement, and the sequence of next steps is often driven by information gathered previously. The process is also iterative. Cultural adaptations occur in many ways, as is evident from the examples presented in this chapter. Sometimes adaptations are made to a specific practice through modification of a program’s content or implementation (as discussed in Chapter 2). In other situations, cultural adaptations may begin holistically and become part of the organizational culture; all programs and practices delivered by the organization then reflect this cultural approach. Despite differences in cultural adaptations and the populations for which they are intended, the three programs presented in this chapter have several common features.
1. The goal for each adaptation is to enable the program to better meet the needs of specific populations and communities the program serves.
2. Each example demonstrates how programs put into practice steps of the adaptation process and implement both types of adaptations (content and implementation), as described in Chapter 2.
3. Each program begins the adaptation process with community engagement and continues to value community engagement at every step in the process. Each program’s goal is to engage all stakeholders in a meaningful and authentic way.
4. Each program uses client and stakeholder feedback to assess program fit and make continual modifications.
5. For each program, building trust was an important initial step in the process. While this is critical for most behavioral health services, it is particularly relevant when working with under-resourced populations. Building trust takes time and is an essential element for successful outcomes.
6. Engagement from community members and other stakeholders with lived experience helped strengthen the effectiveness of each program and its chance for success.
Youth AFFIRM Shelley Craig and Ashley Austin designed, implemented, and evaluated an adapted version of CBT. The adapted program, called AFFIRM, reflects the needs and lived experiences of LGBTQ+ populations. Various settings and communities across the United States have implemented the program since it was first developed in 2012.
Program
AFFIRM is an eight-module, manualized, group CBT curriculum adapted specifically for LGBTQ+ youth and young adults. Schools, child welfare and health centers, behavioral health clinics, and community organizations are implementing the curriculum, both in person and online.
Challenge (steps 1, 2, and 3 in adaptation process)
While leading standard therapy groups for youth, the creators of the AFFIRM program recognized that standard CBT does not focus on LGBTQ+ young people’s unique needs and contexts, which can include discrimination, rejection, bullying, and minority stress. 98 For example, it is difficult for a young person who self-identifies as LGBTQ+ to challenge the automatic thought, “I am worthless,” when the society, community, media, and family may be saying that LGBTQ+ individuals are less worthy than their straight and/or cisgender counterparts. Additionally, studies typically do not track depression or anxiety outcomes for LGBTQ+ youth in standard CBT programs.
Other therapeutic adaptions to CBT have been relevant for specific identities within the LGBTQ+ community (e.g., gay men), but AFFIRM creators wanted a program that would be effective for all individuals in the LGBTQ+ community. Adapting CBT to focus on the common underlying stressors for LGBTQ+ individuals and build social support was a primary objective.
Having identified these challenges, AFFIRM practitioners embarked on an “adapt and evaluate” process. They conducted an extensive community needs assessment and enhanced the standard CBT tenets with additional context, strategies, examples, and modules that speak to the LGBTQ+ experience.
100 Solution (steps 4 and 5 in adaptation process)
Developers embedded a trauma-informed, affirmative practice, and minority stress framework throughout all aspects of the intervention—manual content, therapist training, and implementation. The program uses a CBT approach to explore the impact of structural oppression and discrimination.
Developers adapted the CBT components to reflect the unique and varied elements of the LGBTQ+ experience. Certain CBT tenets are less relevant to the LGBTQ+ population than to other populations. For example, applying the concept of “universalizing,” which is the idea that “everyone goes through this,” to LGBTQ+ specific stressors such as parental rejection, is counterproductive. Using the concept with this population undermines and invalidates the unique experiences of minority stress faced by LGBTQ+ people. Hence, during AFFIRM therapy sessions, therapists help their clients explore automatic thoughts and their triggers through a lens of oppression, stigma, and minority stress.
Developers added modules focused on hope and social supports. A module on hope for the future was added to specifically address hopelessness and suicidality, two common presentations in LGBTQ+ youth. The hope module involves goal-setting for the future and creating a Hope Box, which is an evidence-based tool where clients put tangible items that represent hope for the future (e.g., notes from family, comfort objects, pictures that bring up positive memories) into a container. A module identifying social supports is already part of CBT, and AFFIRM developers adapted this module to include a discussion on building affirming social support networks and how to assess and modify social supports that invalidate LGBTQ+ experiences, identities, and communities.
Developers piloted the adapted components. Before the adapted curriculum was rolled out, developers conducted a feasibility study, resulting in minor modifications to the session pace, processing of key activities, facilitator coaching processes, relevant content examples, and workbook visuals. During the pilot, many participating LGBTQ+ youth stated that it was their first time participating in a program that was designed specifically for them. The experience was validating while increasing trust and buy-in from youth.
Developers gathered regular feedback from youth, the community, and AFFIRM facilitators. Program developers seek continual feedback from community and youth advisory boards (including AFFIRM graduates), as well as from facilitators in community organizations. The developer uses this feedback to inform updates that they regularly make to the participant workbook, facilitator manual, and the training. Updates include implementation processes of telehealth groups102 and the inclusion of relevant identity and regional examples.
There are costs associated with AFFIRM implementation. To facilitate AFFIRM, providers participate in an AFFIRM training, whose cost includes training and the facilitator manual. Providers are encouraged to integrate AFFIRM into their existing services to avoid extra costs for clients. Payment options vary considerably. In many instances, AFFIRM is free for clients (e.g., implemented in schools, provided through grant-funded programs) and in other instances, health insurance may cover the cost.
Outcomes and Other Benefits (steps 6 and 7 in adaptation process)
Longitudinal research on AFFIRM, including randomized controlled trials with LGBTQ+ youth ages 14 to 24, have demonstrated the following mental health outcomes in both in-person and telehealth groups101-105:
• Reduced depression symptoms, as measured by the Beck Depression Inventory (BDI-II)
• Increased coping skills, as measured by the Brief Coping Orientation to Problems Experienced Inventory (COPE)
• Improved stress appraisal, as measured by the Stress Appraisal Measure-Adolescents (SAMA)
• Increased hope, as measured by a modified Adult Hope Scale (AHS)
Lessons Learned
• Organizations should be ready and have the capacity to implement the adapted curriculum, demonstrated through commitment from leadership and staff to serve the unique needs of LGBTQ+ young people.
• Organizations should seek ongoing input from the community and youth served to ensure effective and relevant facilitation and implementation.
• Staff delivering AFFIRM should be willing to engage in training and continued coaching. Staff need to complete the evidence-based AFFIRM training to facilitate the AFFIRM intervention.
• Organizations should avoid assuming that because a facilitator has lived experience in the LGBTQ+ community, it alone qualifies them to deliver the curriculum; competence in CBT as well as LGBTQ+ affirmative practice skills are imperative.
Related Resources
• Affirmative Research Collaborative
• AFFIRM at the Center of Excellence on LGBTQ+ Behavioral Health Equity
