abstract: There are federal mandates attached to funding for behavioral health programs that require the use of evidence-based treatments (EBTs) to treat mental health disorders in order to improve clinical outcomes. However, these EBTs have not been constructed with American Indian/Alaskan Native (AI/AN) populations. There are over 340 EBTs, and only two outcome controlled studies have demonstrated effectiveness with AI/AN populations to treat mental health disorders. AI/AN communities often have to select an EBT that is not reflective of their culture, language, and traditions. Although EBTs are frequently used in AI/AN communities, little is known about the adaptation process of these interventions with the AI/AN population. For this study, a qualitative design was used to explore how American Indian behavioral health (AIBH) organizations in the Southwest adapted EBTs for cultural relevancy and cultural appropriateness. One urban and two tribal AIBH programs were recruited for the study. Over a six-week period, 24 respondents (practitioners and cultural experts) participated in a semi-structured interview. Transcripts were analyzed using the constant comparative analysis approach. As a result, four themes emerged: 1) attitudes towards EBTs, 2) how to build culturally competent clinical skills, 3) steps to adapt EBTs, and 4) internal and external organizational factors required to adopt EBTs. The four themes identify how to build a culturally responsive behavioral health program in Indian country and are the purview of this dissertation. / Dissertation/Thesis / Doctoral Dissertation Social Work 2020

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Manualized, evidence-based treatments (EBTs) for children are being increasingly incorporated in community mental health clinics. Yet, providers hold concerns about the appropriateness of manuals for community populations, as suggested by the research of Jensen-Doss, Hawley, Lopez and Osterberg. Such concerns could lead them to adapt EBTs in the field, potentially diminishing or increasing their effectiveness. Therefore, it is striking how little is known about provider-level manual adaptation in community settings. The present study investigated the extent to which therapists mandated to use a manualized EBT adapt the treatment in the field, including patterns, predictors and outcomes of adaptation. A typology of provider-level manual adaptation was created to describe sessions double-dipped (i.e., repeated), skipped, or flipped (i.e., delivered in reverse order). Patterns of manual adaptation used by a sample of 38 community therapists treating 288 depressed youths with Lewinsohn and colleagues? Adolescent Coping with Depression course (CWD-A) were described. Hierarchical Linear Modeling was used to identify which client and therapist characteristics predict manual adaptation, and whether adaptation is associated with greater improvement or worsening in youths? therapy outcomes. Adaptation was widespread and largely unsystematic, with no significant client predictors of repeats or flips. Sessions were skipped more often for youths belonging to families with higher income and youths with greater pre-treatment symptom severity, but less often for Hispanic and Asian youths relative to Caucasians. A significant portion of variability in adaptation was attributable to therapists, who showed habits in manual adaptation: therapists with more years of experience working at the clinics double-dipped sessions more often, and Hispanic therapists flipped sessions much less often than Caucasian therapists did. Finally, adaptation was significantly related with outcomes, such that doubledips were associated with worsened symptom severity, skips were associated with improved symptom severity, and flips were associated with worsened functioning. Given that these data suggest manualized EBTs are likely to undergo vast adaptation in community settings, and that such adaptation is related to client outcomes, further research is necessary to better inform practitioners about when each type of manual adaptation may be appropriate. Practical implications for implementation efforts are discussed.

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Text in English / The inception of psychology as a practicing profession in 1938 brought with it a continuing scientific struggle geared towards cementing its place as a value-adding health service in the form of psychotherapy. Concepts such as Empirically Supported Treatments (ESTs), Evidence Based Treatments (EBTs) and Evidence Based Practice in Psychology (EBPP) arose out of research attempts to scientifically prove the efficacy of psychological treatment versus psychiatric medications or versus no treatment. This focus on evidence in psychotherapy partly stems from, but also influences public policy in the form of practice and training mandates as well as government and insurance funding policies for psychotherapy. At present ESTs, EBTs and EBPP are the source of polarisation among psychologists who argue for either sides of this controversy, raising questions on a practical/policy level as well as an epistemological level. This thesis differentiates between ESTs, EBTs and EBPP as well as the Common Factors approach and continues to critically investigate the advantages, practical/policy implications and epistemological critiques against these approaches. Some of the identified shortfalls resulting from unwarranted epistemological (empirical) assumptions are addressed by proposing a social constructionist model of therapeutic factors based on social constructionist- and eco-systemic theories. The proposed model allows therapists to employ EBT’s in conjunction with various other (excluded) approaches that are available in their arsenal of treatments. Clinical case studies are used to illustrate the model’s practical operation in therapeutic contexts. / Psychology / Ph.D. (Psychology)

Text in English / The inception of psychology as a practicing profession in 1938 brought with it a continuing scientific struggle geared towards cementing its place as a value-adding health service in the form of psychotherapy. Concepts such as Empirically Supported Treatments (ESTs), Evidence Based Treatments (EBTs) and Evidence Based Practice in Psychology (EBPP) arose out of research attempts to scientifically prove the efficacy of psychological treatment versus psychiatric medications or versus no treatment. This focus on evidence in psychotherapy partly stems from, but also influences public policy in the form of practice and training mandates as well as government and insurance funding policies for psychotherapy. At present ESTs, EBTs and EBPP are the source of polarisation among psychologists who argue for either sides of this controversy, raising questions on a practical/policy level as well as an epistemological level. This thesis differentiates between ESTs, EBTs and EBPP as well as the Common Factors approach and continues to critically investigate the advantages, practical/policy implications and epistemological critiques against these approaches. Some of the identified shortfalls resulting from unwarranted epistemological (empirical) assumptions are addressed by proposing a social constructionist model of therapeutic factors based on social constructionist- and eco-systemic theories. The proposed model allows therapists to employ EBT’s in conjunction with various other (excluded) approaches that are available in their arsenal of treatments. Clinical case studies are used to illustrate the model’s practical operation in therapeutic contexts. / Psychology / Ph.D. (Psychology)