The Cognitive Behaviour Therapist (2014), vol. 7, e20, page 1 of 16doi:10.1017/S1754470X14000233

ORIGINAL RESEARCH

Culturally adapted cognitive behaviour therapy for Maoriwith major depression

Simon T. Bennett1∗, Ross A. Flett2 and Duncan R. Babbage3

1School of Psychology, Massey University, Wellington, New Zealand2School of Psychology, Massey University, Palmerston North, New Zealand3Person Centred Research Centre, Health and Rehabilitation Research Institute, Auckland Universityof Technology, Auckland, New Zealand

Received 14 May 2014; Accepted 9 October 2014

Abstract. Maori are the indigenous people of New Zealand and in 2006 comprisedapproximately 15% of the country’s population. Epidemiological data suggests Maoriexperience rates of depression that are higher than the general population and areless likely to engage in treatment for mental health issues. The main aim of thisstudy was to evaluate the effectiveness of an adapted approach to psychotherapy withMaori. The broad goals of which were to provide empirically grounded guidancefor therapists aspiring to provide best practice to their Maori clients. This paperdocuments the evaluation of a cognitive behavioural therapy (CBT) treatment protocolspecifically designed and adapted for delivery to adult Maori clients with a diagnosis ofdepression. The treatment protocol was administered to 16 Maori clients with a primarydiagnosis of depression. The adapted treatment incorporated Maori processes forengagement, spirituality, family involvement and metaphor. The intervention exhibitedconsiderable promise with large significant reductions in depressive symptomatologyin the participant group. Furthermore, significant reductions in negative cognition wereobserved. This is the first piece of applied clinical research that has examined theeffectiveness of an individual psychological therapy exclusively with Maori and the firstto examine individual psychotherapy outcomes with an indigenous population usingan effectiveness study. The findings have a number of implications for the treatmentof Maori clients with depression. This study provides useful guidelines for cliniciansproviding psychological treatment to Maori and provides strong support for the culturaladaptation of psychological treatment with ethnic minority groups.

Key words: CBT, depression, First Nations, indigenous, Maori

Culturally adapted CBT for Maori

Maori are the indigenous people of New Zealand and according to 2006 census data comprised14.9% of New Zealand’s population of over 4 million (Statistics New Zealand, 2006). Over the

∗Author for correspondence: S. T. Bennett, PhD, School of Psychology, Massey University – Wellington Campus,Private Bag 756, Wellington 6140, New Zealand (email: S.T.Bennett@massey.ac.nz).

© British Association for Behavioural and Cognitive Psychotherapies 2015

2 S. T. Bennett et al.

years subsequent to the European settlement of New Zealand in the late 1700s and early 1800s,Maori experienced considerable loss of land and autonomy (King, 2003). It is postulated bya number of authors that contact with Europeans gave rise to a range of issues that havecontributed to poor economic, social and health outcomes for the Maori population (e.g.Durie, 2001; Walker, 1990).

Maori are disproportionately represented in statistics that indicate that they experiencepoorer health outcomes in relation to non-Maori. The results of Te Rau Hinengaro (The NewZealand Mental Health Survey; Oakley-Browne et al. 2008) have given greater certainty to thepostulated assertion that Maori experience a higher prevalence of common mental disordersthan the rest of the New Zealand population. Specifically, Te Rau Hinengaro reported thatMaori displayed a significantly higher prevalence of mood disorders, anxiety disorders, andsubstance use disorders compared to non-Maori. Mood disorders were extremely pervasivewith 15.7% of Maori experiencing a major depressive episode at some point in their life and24.3% of Maori experiencing ‘any mood disorder’ at some stage in their lives (Baxter et al.2006). These figures indicate that despite the allocation of government resource into the fieldsof health and education aimed at addressing this imbalance, inequities between Maori andnon-Maori in the incidence of mental illness remain significant

Te Rau Hinengaro also reported on the low rate of health service utilization by Maoriwith mental illness. Most telling among the statistics pertaining to service utilization wasthe finding that of those Maori experiencing serious disorders only 52.1% had contact withthe health sector (Baxter et al. 2006). While the Te Rau Hinengaro study was not designedto explore causative explanations for the low rate of service utilization by Maori, the findingswould certainly support the over-arching goal of this study to thread Maori values througha common psychological treatment approach to increase its appeal to Maori service users.Improved service utilization is one of the likely flow-on effects of improving the treatmentexperience for those Maori who do access mental health services.

The essence of New Zealand’s founding document, the Treaty of Waitangi (first signedin 1840) as well as contemporary interpretations of the Treaty (e.g. Durie, 1989; Kawharu,1989), allude to crown/government obligations to ensure equity in terms of access to healthservices and the experience of good health itself. Along with the results of Te Rau Hinengaro,there is strong justification for further research that has the potential to improve psychologicalservice provision and improve mental health outcomes to and for Maori.

Maori ideologies and the inherently Western practice of clinical psychology diverge at anumber of levels. Numerous authors have alluded to the philosophical tensions that existbetween Maori ways of understanding and viewing the world and those of the psychologicaldiscipline (e.g. Abbott & Durie, 1987; Lawson-Te Aho, 1994; Paewai, 1997; Nathan, 1999).These authors have stressed the importance that the psychological profession in New Zealandmust evolve to more adequately support the aspirations of the Maori population. Durie(2004) argued that when the conceptualizations about health held by a specific population aredisregarded it can lead researchers and clinicians towards misleading diagnostic and treatmentdecisions. While Maori are as diverse as any other group, in order for Western approachesto psychology to be adapted and refined to improve their relevance to Maori clientele, it isimportant to consider some of the more common values and beliefs that underpin a Maoriworldview. For some time there has been strong support for the development of a Maorispecific psychology as a mechanism for (among other things) the promotion and bettermentof Maori mental health (Levy, 2007).

Culturally adapted CBT for Maori 3

CBT has been extensively researched and a vast number of well-controlled studies havesupported the efficacy of cognitive behavioural therapy (CBT) in the treatment of depressionover a number of years (e.g. Blackburn et al. 1981; Hersen et al. 1984; Keller et al. 2000;Dubicka, 2008; Soroudi et al. 2008). CBT has also been shown to be an effective interventionfor depression across the lifespan with studies indicating successful outcomes with childrenand adolescents (Curry, 2001), and the elderly (Koder et al. 1996). While the original CBTmanual was developed to treat depression, the core principles of CBT have been adaptedand successfully applied to a range of mental health issues including anxiety disorders (e.g.Dugas & Ladouceur, 2000; Dugas et al. 2003; Pina et al. 2003; Manassis et al. 2004; Wattaret al. 2005), personality disorders (e.g. Koerner & Linehan, 2000; Pretzer & Beck, 1996;Sunseri, 2004), bipolar disorder (e.g. Schmitz et al. 2002; Jones, 2004), and substance abuse(e.g. Linehan et al. 1999; Feeney et al. 2002; Waldron & Kaminer, 2004; Zlotnick et al.2009).

While a number of major studies have utilized clinical trials to investigate and validate CBTas a highly effective treatment for a range of mental disorders in a range of conditions, themajority of these studies have either not collected data related to ethnic identity, or lacked thestatistical power to examine the response of ethnic minority groups to CBT due to the lackof minority representation in controlled trials (Miranda et al. 2005). Concerns were raisedby the Surgeon General of the USA that despite the existence of a range of treatments formental disorder, minority groups were largely omitted from efficacy studies (US Departmentof Health and Human Services, 2005). It has thus been suggested that predictions regardingtreatment outcome should be more modest when applying ‘empirically supported therapies’to non-Western populations (Westen & Bradley, 2005).

A rapidly growing body of literature has provided empirical support for the adaptation ofCBT to make it a more relevant intervention for non-Western cultural groups (e.g. Bernalet al. 2009; Laliberté et al. 2010; Hinton et al. 2011; Bennett & Babbage, 2014; Bennett-Levyet al. 2014). Adaptations to CBT have been recommended across a range of cultural contextsby a number of authors. These have included the incorporation of a spiritual dimension inCBT (e.g. Duarté-Vélez et al. 2010), the integration of collective cultural values (Rossellóet al. 2012), adapted techniques for building a therapeutic alliance (e.g. Asnaani & Hofmann,2012), and an awareness of ideological differences (e.g. Hinton et al. 2012).

This piece of research evaluates what level of impact a culturally adapted cognitivebehavioural therapy approach can have on Maori clients with depression. It sets outto ascertain whether a culturally adapted version of CBT can demonstrate comparablerates of effectiveness, to those reported in the international literature regarding CBT anddepression.

Method

During the preparatory phases of this study, approaches were made to the management ofMaori Mental Health Services. These services are tertiary-level mental health services thatprovide government-funded assessment and treatment for Maori experiencing moderate tosevere Axis I mental disorders. Initial response to the proposal was positive: feedback wasprovided and guidance was given by the service leaders as to further consultation that wouldbe necessary prior to approval being granted for participant recruitment to proceed. Additional

4 S. T. Bennett et al.

consultation was conducted with local tribal bodies as well as consultation with relevantgroups internal to local mental health services.

The original design of this study was revised at various stages in response to feedbackreceived through the consultation outlined above. Significant among these changes was thedecision to expand the inclusion criteria to include individuals with co-morbid psychiatricfeatures. The feedback that emerged from the consultative process indicated that these criteriawould be excessively restrictive given the secondary nature of care provided by Maori mentalhealth services. It was suggested that few if any current clients of these services would meetmore restrictive criteria. This change in the inclusion criteria was consistent with literaturethat has criticized the restrictive inclusion criteria employed by many clinical trials. Suchrestrictions raise questions regarding the practical validity of results given the typicallycomplex nature of clinical populations (Westen & Bradley, 2005). Although this changeintroduced additional confounds and increased variation inherent in the treatment populationit was deemed by the groups consulted with, that it would increase the practical applicabilityof the research.

Participants

To be eligible for this study individuals had to self-identify as Maori, be aged �18 years, andexperience symptoms of depression as their primary presenting issue. Sixteen individuals ofMaori descent participated in this study. The sample ranged in age from 19 to 57 years andincluded five males and 11 females. At the time of their recruitment into the study levelsof depression in the sample as measured by the Beck Depression Inventory - II (BDI-II;Beck et al. 1996) ranged from mild to severe. However the sole participant with a pre-treatment score in the mild range withdrew from the study after attending just two sessions.A range of co-morbid factors were identified by the respective care teams as present amongthe participants in this research. These included alcohol and substance abuse (n = 7), anxietydisorders (n = 6), personality disorders (n = 3), and prior diagnoses of bipolar II disorder(n = 2). However, all of the participants had been given a primary diagnosis of a majordepressive episode. Table 1 provides more detailed demographic information pertaining tothe 16 participants.

Measures

Beck Depression Inventory – 2nd edition (BDI-II). The BDI-II is a 21-item self-report measurewith each answer scored on a scale ranging from 0 to 3. It has excellent face validity andis in wide clinical use in New Zealand (Patchett-Anderson, 1997). The cut-offs suggestedby the authors to describe the severity of depression are: 0–13 minimal depression, 14–19mild depression, 20–28 moderate depression, and 29–63 severe depression. The BDI-II hasbeen shown to have a high 1-week test–retest reliability (Pearson’s r = 0.93), as well as highinternal consistency (α = 0.91) (Beck et al. 1996).

Numerous studies into the effectiveness of CBT for depression have used its predecessorthe BDI, to monitor treatment progress (e.g. Kohn et al. 2002; Gelman et al. 2006; Okazaki& Tanaka-Matsumi, 2006). The BDI-II is a highly clinically valid assessment tool and is usedby healthcare professionals and researchers in a variety of clinical settings. The BDI-II hasalso been found to be sensitive to changes in depression over time (Sprinkle et al. 2002) and

Culturally adapted CBT for Maori 5

Table 1. Participant characteristics and clinical presentation at assessment

Participant Gender Age, yrDepressionseverity at intakea

Antidepressantmedication atintake

Sessionscompleted

S.01 M 57 Moderate-severe Yes 12S.02 F 34 Severe No 12S.03 M 22 Severe No 12S.04 F 30 Moderate-severe No 7S.05 F 26 Severe Yes 12S.06 F 32 Severe Yes 12S.07 F 31 Severe Yes 11S.08 F 49 Mild-moderate No 2S.09 F 36 Severe No 10S.10 F 57 Moderate-severe Yes 12S.11 F 44 Moderate-severe Yes 7S.12 F 40 Severe Yes 12S.13 M 28 Moderate-severe No 10S.14 F 29 Moderate-severe No 7S.15 M 19 Severe Yes 9S.16 M 56 Severe Yes 12

aAs measured by the Beck Depression Inventory – II.

is designed to be able to be completed on multiple occasions, making it a highly suitablemeasure for tracking progress throughout treatment.

A study investigating the psychometric properties of the BDI-II when used with African-American suicide attempters has also given support to the cross-cultural use of the BDI-II.The authors found it to be a ‘reliable and valid measure of depressive symptoms’ in thispopulation reporting a Cronbach’s alpha of 0.94 and moderate convergent validity (r = 0.66)with the Hamilton Depression Rating Scale (Joe et al. 2008).

Automatic Thought Questionnaire (ATQ). The ATQ was developed by Hollon & Kendall(1980) and was designed to measure the frequency that automatic negative thoughts associatedwith depression occurred. The ATQ consists of 30 items comprising a series of negative self-statements that respondents indicate how frequently they experience. It has been constructedand validated using male and female undergraduates as subjects. Split-half reliabilitycoefficients have been recorded at 0.97 and coefficient alphas have been found to be 0.96and it has also been found to show good criterion-related validity in discriminating betweendepressed and non-depressed respondents (Hollon & Kendall, 1980).

Possible scores on the ATQ-30 range from 30 to 150. Hollon & Kendall (1980) report meanscores for depressed individuals on the ATQ-30 of 79.64 (S.D. = 22.29) and mean scores fornon-depressed individuals of 48.57 (S.D. = 10.89).

The cognitive focus of the ATQ makes it a useful measure of the frequency of negativethinking among clients receiving CBT. The ATQ is widely used in CBT outcome research tomeasure the frequency of negative cognition (e.g. Griffiths et al. 2004; Kaufman et al. 2005;Allart-Van Dam, et al. 2007).

6 S. T. Bennett et al.

Procedure

A 12-session adapted cognitive behavioural treatment protocol for Maori with depression wasdeveloped for the purposes of this study. The development of the protocol and the natureof the adaptations are described in detail elsewhere (Bennett, 2009) and is the subject ofa manuscript currently being prepared for submission. However, in brief, the manual wasdeveloped in accordance with culturally relevant literature, CBT literature and in consultationwith an advisory panel. The advisory panel consisted of experienced consultant-level clinicalpsychologists of Maori and non-Maori descent. In addition, the advice of mental healthconsumers and elders (kaumatua) with advanced cultural knowledge was sought. Broadlyspeaking the structure of treatment involved an initial focus on implementing behaviouralinterventions followed by a focus on cognitive techniques commonly associated with CBT.

Each session lasted approximately 1 hour. The participants attended an average of 8.8/12sessions; however, after removing a subject who only attended two sessions this averageincreased to 9.2/12 sessions. The number of sessions attended by each participant can beseen in Table 1.

Clinical staff (psychiatrists and care managers) from Maori Mental Health Services wereoriented to the study. Clients who met inclusion criteria for referral to the study, were giveninformation to read and discuss with their family. On all occasions the initial approach topotential participants was made through the case manager who facilitated the early stages ofengagement with potential participants.

At the time that fieldwork was undertaken the first author was a Maori senior clinicalpsychologist with 7 years clinical experience in both mainstream and specialist Maori mentalhealth clinical settings.

Treatment

The 12-session treatment manual that was developed for the purposes of this studyincorporated a number of specific Maori values into the approach to treatment. These wereconceptualized in terms of a series of domains as outlined below

The domain of connectedness (Whakawhanaungatanga). Current trends in internationalresearch suggest that a degree of therapist self-disclosure can have a positive impact onthe therapeutic alliance and treatment outcome (e.g. Barrett & Berman, 2001; Knox & Hill,2003). The sentiments of the advisory panel were consistent with the research and literaturerecommending adaptation of CBT with ethnic minority groups which suggests that the sharingof personal information between the therapist and client is encouraged as part of the initialengagement with Latino clients (Organista, 2006; Interian & Díaz-Martínez, 2007).

CBT has been characterized by a more active deportment on the part of the therapist thatallows for higher levels of emotional support and empathy than would be typical of the insight-oriented therapies (Keijsers et al. 2000). Despite this, therapist self-disclosure is a seldom usedtechnique in CBT; for instance one study comparing CBT and insight-oriented therapies foundno significant difference in the frequency of therapist self-disclosures (Stiles et al. 1988).Reservations have also been raised regarding the clinical benefits of self-disclosure by thetherapist with one review concluding that research findings suggested therapist self-disclosurewas not a powerful therapeutic intervention (Orlinsky & Howard, 1987).

Culturally adapted CBT for Maori 7

The information disclosed to clients participating in this study included tribal affiliation,working history, and family background. Where personal connections were made, orsimilarities identified between the client and the therapist these were acknowledged andfurther discussed. For example, were it to emerge from the self-disclosure process that theclient and therapist were from the same tribe, these similarities would be acknowledgedand discussed with reference to any connections of significance. The goal of thesedisclosures was described by one of the advisory group as a crucial part of the process ofwhakawhanaungatanga and an integral part of working effectively with Maori clients.

The domain of spirituality (Te taha wairua). In the current study Maori proverbs (whakatauki)or Maori prayer (karakia) were utilized to open and close sessions with clients. Rather thanthese being seen as a purely ritualistic or procedural, proverbs or prayer were selected that hadsome relevance to the phase of treatment and were explained and discussed with the client.

The domain of extended family (Te taha whanau). The notion that family can play a protectiverole in relation to mental illness and stress has long been promoted by Maori academics (e.g.Durie, 1999; Herbert, 2001; Diamond, 2005; Pitama et al. 2007) and Te taha whanau is oneof Durie’s (1984) proposed cornerstones of Maori health. In his related commentary Hirini(1997) pointed out that the individualized and thus less collective focus of CBT was a potentialbarrier to engaging effectively with Maori clients and their whanau. He gave the examplethat CBT interventions which fostered independent thought or assertiveness may contradictcollective Maori values. Past authors have likewise highlighted that the individual focus ofWestern psychotherapies reflects the more individualistic and independent culture of Westernsociety (e.g. Gelman, 2004). This has, however, been contrasted with, for example, the culturalperspective of eastern cultures who place a greater emphasis on mutual dependence andloyalty to one’s family (Toukmanian & Brouwers, 1998).

Therefore for the purposes of the current study a more inclusive approach to treatment wasutilized. This included extending an invitation to participants in the initial appointment letterto bring whanau support to initial sessions and involving whanau as active participants intreatment objectives (e.g. participating in behavioural experiments).

The domain of metaphor (Whaikorero). The majority of psycho-educational materialutilized by clinical psychologists uses Eurocentric examples to illustrate important cognitivebehavioural concepts such as the connection between thoughts and emotions. An example ofthis is the psycho-educational material information used in the popular CBT manual MindOver Mood (Greenberger & Padesky, 1995). Mind Over Mood uses a series of vignettes toillustrate the key tenets of CBT in an applied manner. However, the vignettes and associatedcharacters utilized tend to reflect mainstream cultural influences in the USA. While this maybe an understandable reflection of the original target audience, this becomes a limitation whenused beyond that context. Vignettes were therefore utilized that were deemed more resonantwith Maori experience in New Zealand.

Furthermore, ‘culturally appropriate’ metaphor in the form of Maori proverbs also knownas whakatauki, were incorporated. A series of appropriate proverbs were identified thathad relevance to the therapeutic goals of CBT and these were also incorporated intotreatment.

8 S. T. Bennett et al.

Table 2. Mean scores in clinical outcome measures across assessment points

Baseline Post-treatment 6-month follow-upMeasure (n = 16) (n = 14) (n = 15)

BDI-II 28.69 (11.15) 10.71 (13.86) 10.93 (14.81)ATQ 97.50 (25.48) 71.21 (28.56) 65.93 (28.22)

BDI-II, Beck Depression Inventory – II; ATQ, Automatic Thought Questionnaire.

Table 3. Wilcoxon statistics comparing pre-treatment means withpost-treatment and follow-up data

Outcome measure Wilcoxon statistic

BDI-II: baseline → post-treatment −3.414∗∗

BDI-II: baseline → 6-month follow-up −3.466∗∗

ATQ: baseline → post-treatment −3.108∗∗

ATQ: baseline → 6-month follow-up −3.351∗∗

BDI-II, Beck Depression Inventory – II; ATQ, Automatic ThoughtQuestionnaire.∗∗p<0.01.

Results

Table 2 presents the treatment completer data for the BDI-II and ATQ scales. It displayspre- and post-treatment BDI-II means and standard deviations for the paired samples. Thesestatistics allow us to determine the ‘direction’ of any difference between means. The tableshows that the mean pre-treatment BDI-II score is higher than the 1-month and 6-monthpost-treatment scores indicating that on average depressive symptoms decreased followingthe intervention. Mean depression scores decreased from mean = 28.69 (S.D. = 11.15) pre-treatment to mean = 10.71 (S.D. = 13.86) post-treatment. This reduction was sustained at6-month follow-up with mean depression scores of 10.93 (S.D. = 14.81).

Furthermore, ATQ scores displayed a negative trend whereby post-treatment and follow-upscores were lower than the baseline scores. This indicates that negative rumination reducedas a consequence of the treatment. From pre-treatment to post-treatment mean ATQ scoresreduced from 97.50 (S.D. = 25.48) to 71.21 (S.D. = 28.56)†. Six-month follow-up scoresindicated that this was sustained with scores of mean = 65.93 (S.D. = 28.22).

The Wilcoxon signed rank test is a non-parametric test that is used as an alternative tothe Student’s t test for comparing means when the normal distribution of the sample cannotbe assumed. A study in the area of CBT adaptation for minority cultural groups that used thesame design as the current research (Interian et al. 2008) utilized the Wilcoxon test to comparemeans. The Wilcoxon statistics for this dataset are presented in Table 3.

The Wilcoxon test showed that the difference between baseline and post-treatment scoreswere significant for both of the clinical outcome variables. In addition the 6-month follow-up data for the BDI-II and the ATQ was significantly different from baseline data. These

†The authors of the ATQ (Hollon & Kendall, 1980) report means of 79.64 (S.D. = 22.29) among depressed studentsand 48.57 (S.D. = 10.89) among non-depressed students.

Culturally adapted CBT for Maori 9

Table 4. Effect size statistics for clinical outcome measures using three different standardizers

Effect size calculation using two Effect size calculation using twodifferent estimates of variability different estimates of variabilityPre-treatment → post-treatment Pre-treatment → 6-month follow-up

Outcome Hedges’ g Hedges’ gmeasure (adjusted) Change in ES (adjusted) Change in ES

BDI-II 1.368 1.623 1.390 1.664ATQ 0.988 1.072 1.120 1.277

ES, Effect size; BDI-II, Beck Depression Inventory – II; ATQ, Automatic Thought Questionnaire.

findings further corroborate the t test results, which indicated a significant difference betweenthe means of pre- and post-treatment scores.

Having established that a significant difference between means existed for each of theclinical outcome measures administered as part of the assessment, treatment effects werecalculated for the clinical outcome variables. A Hedges’ g effect size calculation wasconducted on both of the dependent variables related to clinical outcome. Table 4 presents theadjusted value for Hedges’ g for the BDI-II and ATQ as well as the change effect size whichwas calculated by dividing the average difference between means by the standard deviation ofthe difference scores. (Two effect sizes were calculated to facilitate the comparison of thesefindings with studies that utilized between-subjects methodology.)

Cohen (1988) tentatively defined effect sizes between 0.2 and 0.3 as small, around 0.5as medium, and greater than 0.8 as large. Using these criteria it can be inferred that largetreatment effect sizes were observed for the BDI-II and ATQ. These large treatment effectswere observed in comparing baseline data with both post-treatment and follow-up data.

Discussion

This study has investigated the effectiveness of a culturally adapted CBT treatment protocolwith a group of clinically depressed Maori from a Community Mental Health Service in theWellington region of New Zealand. Statistical analyses conducted on the grouped data showedthat the reductions in mean scores for depressive symptoms and negative cognition followingtreatment were significant. Treatment effect statistics were calculated for both of the clinicaloutcome measures administered. All of the effect size statistics indicated that the interventionhad a significant impact on reducing depressive symptoms and negative cognition.

There are, however, some limitations of this research that must be acknowledged.Significant among these was that this was a naturalistic study without a true control group.A larger scale study into the adaptation of CBT with Maori might utilize a between-subjectsdesign and administer a non-adapted version of CBT to a control group. Despite the fact thatMaori are over-represented in negative mental health statistics pertaining to the diagnosis ofdepression, we are still some way from being able to provide an inherently ‘Maori definition’of the depression construct. This was beyond the scope of the current study; however, itis acknowledged that utilizing DSM criteria and measuring symptoms with psychometricinstruments based in Western ideology is not ideal for a study that adapts CBT on the basis ofassumed deficits in Western models of treatment.

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Significant differences between baseline and post-treatment scores, and baseline andfollow-up scores on all of the clinical outcome measures that were analysed provid strongsupport for the effectiveness of the intervention and thus the cultural adaptation of CBT forMaori. These findings of significant change raise a number of issues that can be consideredfrom several angles.

It could be argued that these findings are not entirely surprising given the weightof international literature that validates CBT as an effective intervention for depression.However, it should be noted that this research is the first effectiveness study evaluating theindividual delivery of CBT exclusively with Maori clients. The findings therefore represent ahighly relevant and original contribution to our knowledge regarding effective treatment and‘best practice’ with depressed Maori clients.

In comparing the effect sizes obtained in this study with those reported in other research,it is important that comparable statistics are used (i.e. those that have been calculated in thesame metric). Two different effect sizes were calculated in order that the findings could becompared with studies that used a repeated-measures design (i.e. the ‘change’ effect size)and those that used a between-subjects design (i.e. Hedges’ g). This study did not includea between-subjects control and therefore the most meaningful comparisons should be madecomparing the ‘change’ effect size obtained in this study with those reported by other studiesthat have used a within-subjects design.

Studies that employed a within-subjects design to examine the efficacy of CBT have tendedto report large effect sizes. The current research compares favourably with within-subjectsstudies which have applied CBT in general clinical settings (e.g. Gloaguen et al. 1998). Intheir study, which employed an almost identical design in investigating the efficacy of CBTwith a minority ethnic group, Interian et al. (2008) reported very large effect sizes in relationto depressive symptoms. Specifically these effect sizes were 2.71 comparing pre-treatmentwith post-treatment and 2.53 comparing pre-treatment with 6-month follow-up. While thesevalues are considerably higher than the change effect size calculated for the current study (1.62and 1.66, respectively) these authors used a different moderator (i.e. the baseline standarddeviation) in calculating their effect sizes. When the pooled standard deviation is applied theseeffect sizes reduce to the more comparable values of 1.79 (pre-treatment to post-treatment)and 1.76 (pre-treatment to follow-up).

It is also worthwhile contrasting the results with those that have compared CBT with awaitlist or no-treatment control. A meta-analysis of 20 such studies examining the efficacy ofCBT for depression, reported an overall effect size of 0.82 (Gloaguen et al. 1998) considerablylower than the Hedges’ g effect sizes calculated for this study (1.40 and 1.42). While cautionshould be exercised in comparing the results of this research with those reported in studiesthat have employed between-subjects designs, it could be inferred from these comparisonsthat appropriately delivered CBT can be at least as effective in treating depression in Maorias the international outcome literature would suggest.

An important aspect that distinguishes this study from other research examining CBT withminority groups is that it employed a culturally adapted version of CBT. Therefore in drawinginferences from this research it should be highlighted that the findings provide empiricalsupport for a form of CBT that has been culturally tailored specifically for the participantswho received the treatment. Conversely, it cannot be assumed that these findings support theuse of generic forms of CBT with Maori. This has clear implications for those who purportto work from a scientist-practitioner model as it provides support for culturally adapted CBT

Culturally adapted CBT for Maori 11

when working with Maori clients but stops short of supporting more general versions of CBT.We acknowledge that, this was an artefact of the research design which ideally would haveincluded a standard CBT group as a control. However, in comparing the results of this studywith others that have delivered generic/non-adapted forms of CBT to ethnic minority groups(e.g. Organista et al. 1994; Miranda et al. 2005), it is possible to infer that making specificadaptations as has been done in this study leads to better treatment outcomes in ethnic minoritypopulations. In this respect the findings are congruent with those of Interian et al. (2008), Ottoet al. (2003), and Hinton et al. (2004) who all reported significant changes in key outcomeareas and large effect sizes after adapting CBT for use with specific populations.

The conclusions of this research make a distinctive contribution to the literature onpsychological treatment of ethnic minority populations. Epidemiological studies from aroundthe world would suggest that most countries are yet to refine their mental health servicesto fully meet the needs of their indigenous and ethnic minority populations. However,the findings of this study provide strong support for the notion that cultural adaptation ofpsychological therapy can be associated with positive treatment outcomes for Maori. Afterall, there can be little question that the provision of a mental health service which not onlyacknowledges but actively celebrates the uniqueness of a client’s ethnic identity represents astate of affairs to be highly coveted.

Acknowledgements

The authors gratefully acknowledge the generous support of the Health Research Councilof New Zealand (HRC) who made this research possible through the award of a ClinicalResearch Fellowship to the first author.

Declaration of Interest

None.

Recommended follow-up reading

Durie M (2004). Understanding health and illness: research at the interface between science andindigenous knowledge. International Journal of Epidemiology 33, 1138–1143.

Interian A, Allen LA, Gara MA, Escobar JI (2008). A pilot study of culturally adapted cognitivebehaviour therapy for Hispanics with major depression. Cognitive and Behavioural Practice 15, 67–75.

Interian A, Díaz-Martínez AM (2007). Considerations for culturally competent cognitive-behaviouraltherapy for depression with Hispanic patients. Cognitive and Behavioural Practice 14, 84–97.

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Learning objectives

1. An introduction to considerations in the adaptation of CBT with Maori.2. Provide guidelines for clinicians wishing to provide culturally sensitive evidence

based practice to minority cultural groups.3. Orient the reader to alternate quantitative methodology for trialling innovative

practice with ‘high need’ but relatively small populations.