Using Mindfulness- and Acceptance-Based Treatments With Clients From Nondominant Cultural and/or Marginalized Backgrounds: Clinical Considerations, Meta-Analysis Findings, and Introduction to the Special Series
Open accessAbstract
A growing body of research suggests that mindfulness- and acceptance-based principles can increase efforts aimed at reducing human suffering and increasing quality of life. A critical step in the development and evaluation of these new approaches to treatment is to determine the acceptability and efficacy of these treatments for clients from nondominant cultural and/or marginalized backgrounds. This special series brings together the wisdom of clinicians and researchers who are currently engaged in clinical practice and treatment research with populations who are historically underrepresented in the treatment literature. As an introduction to the series, this paper presents a theoretical background and research context for the papers in the series, highlights the elements of mindfulness- and acceptance-based treatments that may be congruent with culturally responsive treatment, and briefly outlines the general principles of cultural competence and responsive treatment. Additionally, the results of a meta-analysis of mindfulness- and acceptance-based treatments with clients from nondominant cultural and/or marginalized backgrounds are presented. Our search yielded 32 studies totaling 2,198 clients. Results suggest small (Hedges' g=.38, 95% CI=.11 − .64) to large (Hedges' g=1.32, 95% CI=.61 − 2.02) effect sizes for mindfulness- and acceptance-based treatments, which varied by study design.
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- Findingown data
The effect sizes varied by study design.
“which varied by study design.”
Quote in the paperNot a substantial claim - Findingown data
The meta-analysis found effect sizes for mindfulness- and acceptance-based treatments ranging from small (Hedges' g=.38, 95% CI=.11 − .64) to large (Hedges' g=1.32, 95% CI=.61 − 2.02).
“Results suggest small (Hedges' g=.38, 95% CI=.11 − .64) to large (Hedges' g=1.32, 95% CI=.61 − 2.02) effect sizes for mindfulness- and acceptance-based treatments, which varied by study design.”
Quote in the paperSubstantial claim - Findingown data
Studies using an active treatment (k=9) had an average effect size of g=.67.
“followed by studies that used an active treatment (k=9, g=.67)”
Quote in the paperNot a substantial claim - Findingown data
Studies using a pre-post design (k=11) had an average effect size of g=.57.
“and studies using a pre-post design (k=11, g=.57)”
Quote in the paperNot a substantial claim - Findingown data
The meta-analysis found effect sizes ranging from small to large, with Hedges' g between .38 and 1.32.
“The results showed small to large effect sizes (Hedges' g range=.38 to 1.32; where .2 is a small effect, .5 is a medium effect, and .8 is a large effect).”
Quote in the paperSubstantial claim
- Findingown data
The median number of participants in each study included in the meta-analysis was 28.
“The median number of participants in each study included in the meta-analysis was n=28”
Quote in the paperSubstantial claim - Findingown data
The overall effect size across all aggregated studies was g=.69.
“we aggregated the studies and examined the overall effect size (g=.69)”
Quote in the paperSubstantial claim - Findingown data
The removal of the four asymmetric studies had little impact on the overall treatment effect size.
“removing the asymmetric studies (n=4) had minimal effect on the overall treatment effect size”
Quote in the paperSubstantial claim - Findingown data
Rosenthal's fail-safe N was 1,986 studies.
“The fail-safe N was 1,986 studies (observed studies z=15.32, p<.001)”
Quote in the paperSubstantial claim - Findingown data
Studies comparing an acceptance- or mindfulness-based treatment to treatment as usual (k=5) had the smallest average effect size, g=.38.
“Studies comparing an acceptance- or mindfulness-based treatment to treatment as usual demonstrated the smallest effect sizes on average (k=5, g=.38)”
Quote in the paperNot a substantial claim - Findingown data
Studies with a no-contact or waitlist condition (k=7) had an average effect size of g=1.32.
“Studies that included no-contact or waitlist condition (k=7), on average, demonstrated the largest effect size (g=1.32)”
Quote in the paperNot a substantial claim - Findingown data
The trim-and-fill adjusted overall effect size was g=.81 (95% CI [.55, 1.07]).
“Trim and Fill Adjusted g=.81, 95% CI [.55 − 1.07]”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Duval & Tweedie, 2000 source
Not checked in the free run.
- Findingown data
Only a small number of studies provided details about the theoretical rationale or adaptation considerations for a specific demographic group.
“relatively few studies included information on the theoretical rationale or considerations in adapting the treatment for a specific demographic group”
Quote in the paperSubstantial claim - Premisecitation
Many ABBTs take the stance that sociopolitical and historical forces shape how clients experience and express distress.
“The therapeutic stance in many ABBTs is that the client's experience is influenced by sociopolitical and historical factors that affect the way that distress is experienced and expressed (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Hayes, Luoma, Bond, Masuda, & Lillis, 2006 source
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- Premisecitation
Treatment outcome research increasingly indicates that combining acceptance and mindfulness principles with cognitive behavior therapies may reduce suffering and improve quality of life.
“A growing body of treatment outcome research suggests that the integration of acceptance and mindfulness principles with cognitive behavior therapies shows promise in ameliorating human suffering and improving quality of life (Baer, 2003; Grossman, Niemann, Schmidt, & Walach, 2004).”
Quote in the paperSubstantial claim0 of 2 sources checked - Interpretationreasoning
Acceptance- and mindfulness-based treatments may help address particular concerns of people from nondominant or marginalized backgrounds.
“may show promise in addressing some of the unique concerns of individuals from non-dominant cultural and/or marginalized backgrounds.”
Quote in the paperSubstantial claim- Rests on an assumption: Research on whether these treatments are relevant and acceptable for people from nondominant, traditionally underserved backgrounds is at an early stage.
- Premisecitation
Presenting MBSR as education rather than as mental health care effectively reduced Hispanic women's hesitation about seeking mental health services.
“Roth and Robbins (2004) found that promoting MBSR as an educational program rather than a mental health program was an effective method to address apprehension of seeking mental health services among Hispanic women.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Roth and Robbins (2004) source
Not checked in the free run.
- Premisecitation
Among traditionally underserved groups such as African Americans and older adults, perceived stigma is linked to willingness to use mental health services.
“Perceived stigma has been demonstrated to be related to willingness to receive mental health services among members of traditionally underserved populations such as African Americans and older adults (Conner et al., 2010).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Conner et al., 2010 source
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- Interpretationreasoning
Broadly distributing evidence-based treatments without weighing cultural adaptations or refinements that could boost effectiveness may widen mental health disparities in the U.S.
“Although it is certainly true that a goal of developing treatment variations for every cultural group is impractical and likely unhelpful, broadly disseminating evidence-based treatments without considering the culturally relevant adaptations or refinements that might increase their effectiveness has the potential to widen the gap of mental health disparities in this country.”
Quote in the paperSubstantial claim - Interpretationreasoning
Failing to explore key sociocultural factors in therapy may unintentionally make clients feel responsible for their distress.
“One cost associated with such a narrow focus is that important sociocultural factors that may be influencing client behaviors will not be explored in therapy, which can inadvertently lead clients to feel that they are to blame for their distress.”
Quote in the paperSubstantial claim - Interpretationreasoning
A contextualized ABBT approach may appeal to clients from nondominant or marginalized backgrounds who distrust the mental health system and expect therapy to blame them for their situation.
“This contextualized approach may resonate with clients from nondominant cultural and/or marginalized backgrounds who, due to understandable mistrust of the mental health system, may assume that they will be blamed in therapy for their current circumstances.”
Quote in the paperSubstantial claim - Premisecitation
The values CBT stresses-individualism, present functioning, assertiveness, rationality, and behavior change-may not be shared by all clients, especially those from non-Western or nondominant backgrounds.
“In particular, the emphasis placed in cognitive behavioral therapy (CBT) on individualism, present functioning, assertiveness, rationality, and behavior change reflects values that may not be shared by all clients, particularly those from non-Western/nondominant cultural backgrounds (Hays, 2009).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Hays, 2009 source
Not checked in the free run.
- Interpretationown data
The trim-and-fill analysis suggests an absence of publication bias.
“suggesting an absence of publication bias”
Quote in the paperNot a substantial claim - Premisecitation
Providers achieve the best outcomes when they can adjust their therapeutic focus flexibly to fit each client's needs.
“In general, mental health providers are most effective when they can flexibly shift their therapeutic focus to meet the needs of their clients (D. W. Sue & Sue, 2003).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites D. W. Sue & Sue, 2003
Not checked in the free run.
- Study design and conductreasoning
The analysis used Hedges' g as a conservative adjustment for small samples.
“Next, an estimation for Hedges' g (Hedges, 1981) was applied as a conservative measure to correct for sample size.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Hedges, 1981 source
Not checked in the free run.
- Interpretationown data
The initial findings offer encouraging evidence for the usefulness of acceptance and mindfulness-based treatments among diverse, underserved populations.
“While these initial findings provide some promising support for the utility of acceptance and mindfulness-based treatments with people from diverse, underserved backgrounds”
Quote in the paperSubstantial claim
- May combine two claims. 8
- Classified as probably not a substantial claim. 9
May combine two claims.
Findingown dataThe meta-analysis search identified 32 studies with 2,198 participants.
“Our search yielded 32 studies totaling 2,198 clients.”
- Also stated in: § Method · plain
“This resulted in 32 studies that were retained for analysis, and included 2,198 participants (see Table 1).”
Quote in the paperSubstantial claim- Also stated in: § Method · plain
May combine two claims.
PremisecitationClinical psychology has drawn criticism for neglecting clients' multicultural and community contexts and concentrating too much on the isolated individual.
“Clinical psychology has generally been criticized for deemphasizing the importance of viewing individuals within their multicultural and community contexts, instead focusing too narrowly on the individual in isolation (Nagayama Hall, 2005).”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Nagayama Hall, 2005 source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationLanguage conveys cultural information and is tied to how emotions are expressed and experienced.
“Language not only provides important information about a person's culture, but it also relates to the expression and experience of emotions (Barona & Santos de Barona, 2003).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Barona & Santos de Barona, 2003
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Probably not a substantial claim: may not pass S3 (load-bearing).
InterpretationreasoningThe dialectical stance in some acceptance- and mindfulness-based treatments may appeal to clients who see systemic oppression and discrimination as leaving them little control over their environment.
“may resonate with clients who feel that they lack control over their environment due to systemic oppression and discrimination.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim. May combine two claims.
InterpretationreasoningCombining validation and change in ABBTs may lessen the power imbalance typical of psychotherapy and support a collaborative alliance.
“This unique combination of validation and change also has the potential to minimize the power dynamic inherent in traditional psychotherapeutic communication and facilitate a collaborative therapeutic alliance.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationcitationClients from marginalized backgrounds who doubt therapy's effectiveness may feel misunderstood or ignored if their broader life context is neglected, which can lead them to drop out early.
“Clients, particularly those from marginalized backgrounds who may come to therapy with some skepticism about its effectiveness (S. Sue, 2006), may feel misunderstood or unheard when the full context of their life is not attended to, resulting in early termination of therapy (Comas-Diaz, 2006).”
Quote in the paperSubstantial claim0 of 2 sources checkedMay combine two claims.
PremisecitationResearch indicates that older adults need more education about therapy than younger adults, often because therapy's purpose and function are less familiar to them.
“Older adults, in particular, have been found to require more psychoeducation about the process of therapy than younger adults, as they are often less familiar with the purpose and function of therapy (Edelstein, Northrop, & MacDonald, 2009).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Edelstein, Northrop, & MacDonald, 2009
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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationCohen's d is slightly biased and tends to inflate effect sizes, especially when samples are small.
“Although in most cases the difference between Cohen's d and Hedges' g is negligible, Cohen's d has been shown to have a slight bias and to overestimate the size of the effect, particularly in situations where the sample size is small (Borenstein, Hedges, Higgins, & Rothstein, 2009).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Borenstein, Hedges, Higgins, & Rothstein, 2009
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Classified as probably not a substantial claim.
PremisecitationA selective and directive approach to adapting evidence-based treatments for particular communities is appropriate, where adaptations are indicated when a clinical problem occurs in the context of sociocultural factors and standard treatment does not address contextually specific risk factors.
“Lau (2006) suggests a selective and directive approach to the adaptation of evidence-based treatments for particular communities.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Lau (2006) source
Not checked in the free run.
Classified as probably not a substantial claim.
Study design and conductnone givenA random effects model, chosen according to study design, produced the summary effect.
“The summary effect was then calculated using a random effects model based on study design.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S4 (based).
InterpretationreasoningTaking a client-centered approach inherently supports culturally responsive mental health care.
“Client-centered approaches to treatment naturally facilitate culturally responsive mental health treatment.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
Study design and conductcitationPre-post effect sizes were computed with a global r=.7 correction applied to outcome measures.
“In calculating pre-to posttreatment effect sizes we used a global correction of r=.7 (Rosenthal, 1991) applied to study outcome measures.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites Rosenthal, 1991
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationThe selective and directive approach relies on data to inform adaptations and discourages unnecessary adaptations that threaten treatment fidelity.
“The approach is directive in that it relies on data to inform the adaptations. This approach discourages unnecessary adaptations that threaten the fidelity of the evidence-based treatment.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites Lau (2006) source
Not checked in the free run.
The paper relies on this without support.
The generalizability of findings on acceptance- and mindfulness-based treatments is limited because study samples are not demographically representative of the U.S. population.
“Despite growing evidence for the efficacy of acceptance- and mindfulness-based treatments across a range of disorders, the generalizability of these findings is limited by samples that do not represent the full demography of the U.S. population.”
The paper relies on this without support.
Research on whether these treatments are relevant and acceptable for people from nondominant, traditionally underserved backgrounds is at an early stage.
“In particular, research on the relevance to and acceptability of these treatments with individuals from nondominant, traditionally underserved backgrounds is in its infancy.”
The paper relies on this without support.
No prior meta-analysis had systematically examined how useful acceptance- and mindfulness-based treatments may be for clients from diverse backgrounds.
“To our knowledge, this is the first meta-analytic investigation that systematically explores the potential utility of acceptance- and mindfulness-based treatments with clients from diverse backgrounds.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In a meta-analysis whose primary aim was to examine mindfulness meditation's effectiveness among underserved populations, less than 30% of included studies had people of color samples.
“even in a meta-analysis where the primary aim was to examine mindfulness meditation’s effectiveness among underserved populations, less than 30% of studies included had POC samples [30].”
From App-Based Mindfulness Meditation for People of Color Who Experience Race-Related Stress: Protocol for a Randomized Controlled Trial (2022) · cites this paper as [30]
The Meta-Analysis and Method sections confirm that the paper reviewed treatments for underserved populations and retained 32 studies. But the review covered both mindfulness- and acceptance-based treatments, not mindfulness meditation alone. Our copy does not give the proportion of included studies with people-of-color samples, so it does not substantiate the less-than-30% figure. (LLM, conf=0.84)
Experimental — accuracy not yet measuredEvidence-based treatment (mindfulness meditation) continues to be understudied among POC in both traditional and digital formats.
“Despite extensive evidence showing the negative mental health effects of race-related stress in POC [6-11,14-17] and the promise of mindfulness meditation to help these individuals cope [20-24,26,30-32,79], this evidence-based treatment continues to be understudied among this high-risk population in both traditional [30,35,36] and digital formats [46-48].”
From App-Based Mindfulness Meditation for People of Color Who Experience Race-Related Stress: Protocol for a Randomized Controlled Trial (2022) · cites this paper as [30]
The Abstract says research on mindfulness- and acceptance-based treatments with traditionally underserved groups is in its infancy. The Method includes non-White participants and excludes treatments not conducted in person, supporting the traditional-format portion attributed to this source. The paper discusses a broader class of treatments, however, rather than establishing the claim specifically for mindfulness meditation; the digital-format portion has separate citations. (LLM, conf=0.82)
Experimental — accuracy not yet measuredMindfulness meditation has promise to help POC cope with race-related stress.
“Despite extensive evidence showing the negative mental health effects of race-related stress in POC [6-11,14-17] and the promise of mindfulness meditation to help these individuals cope [20-24,26,30-32,79], this evidence-based treatment continues to be understudied among this high-risk population in both traditional [30,35,36] and digital formats [46-48].”
From App-Based Mindfulness Meditation for People of Color Who Experience Race-Related Stress: Protocol for a Randomized Controlled Trial (2022) · cites this paper as [30]
In “ABBTs and Underserved Populations” (page unavailable), the paper suggests that acceptance- and mindfulness-based treatments may help marginalized clients respond to distress associated with systemic oppression and discrimination. That supports the claim’s sense of promise, but the paper discusses broader treatments rather than showing that mindfulness meditation specifically helps people of color cope with race-related stress. (LLM, conf=0.88)
Experimental — accuracy not yet measuredPerson-driven and values-based frameworks allow treatment individualization and cultural adaptation, potentially improving culturally sensitive conceptualization and treatment for racial/ethnic minority individuals with anxiety and depression.
“person-driven and values-based frameworks provides an opportunity to individualize treatment and actively address cultural considerations and important contextual challenges to improve culturally sensitive conceptualizations”
From A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults. (2018) · cites this paper as Fuchs, Lee, Roemer, & Orsillo, 2013
It has been proposed that ERT and other contemporary evidence-based interventions may work for diverse populations because they focus on values and conceptualization-based treatment.
“it is posited that interventions such as ERT and other contemporary, evidence-based interventions (e.g., ABBT) may be effective in treating these populations due to their focus on values and conceptualization-based treatment (Fuchs, Lee, Roemer, & Orsillo, 2013; Persons, Fresco, & Ernst, in press)”
From A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults. (2018) · cites this paper as Fuchs, Lee, Roemer, & Orsillo, 2013
Studies have actively discussed how ACT can be tailored to fit diverse cultural backgrounds and values.
“Studies have actively discussed how ACT can be tailored to fit diverse cultural backgrounds and values.[30][31][32]”
From Differential associations of Acceptance and Commitment Therapy processes with psychological distress across racial groups. (2026) · cites this paper as [30]
Prior research adapting mindfulness-based treatments for diverse populations has often lacked explicit considerations or justifications for adapting the approach for the specific group.
“Prior research adapting mindfulness-based treatments for diverse populations has often lacked explicit considerations or justifications for adapting the approach for the specific group (Fuchs et al., 2013).”
From The Application of Mindfulness for Individuals Living with HIV in South Africa: a Hybrid Effectiveness-Implementation Pilot Study (2018) · cites this paper as Fuchs et al., 2013
Statistics recomputed
Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.
- Consistentz = 15.32reported p < .001 · recomputed p < .001
“z=15.32, p < .001”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Coauthor surname differs between the overview and reference
MinorThe overview names the fifth author of the Dutton et al. article as Myers, while its reference entry names that author Mylers.
“Dutton, Bermudez, Matas, Majid, and Myers (2013-this issue)”
“Dutton MA Bermudez D Matas A Majid H Mylers NL 2013”
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“Despite extensive evidence showing the negative mental health effects of race-related stress in POC [6-11,14-17] and the promise of mindfulness meditation to help these individuals cope [20-24,26,30-32,79], this evidence-based treatment continues to be understudied among this high-risk population in both traditional […”
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“More research is needed to determine optimal strategies for implementation of MBSR (Riley & Kalichman, 2015), especially when adapting for resource-limited, cross-cultural settings (Fuchs et al., 2013).”
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Cultural adaptation of ACT to support caregivers of autistic Latino children: A pilot study
Cañón, L. F., Gould, E. R., Sandoz, E. K., Moran, O., & Grimaldi, M. A. (2023) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2023.03.003 · Cited by 11 · see citing works
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“In addition, experts noted that ACT is a flexible approach that can be adjusted to meet the needs of participants in a given context [39] and four session ACT based treatments have been tested and found effective [40].”
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Mindfulness and acceptance-based behavioral therapies
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- Authors
- Fuchs, C., Lee, J. K., Roemer, L., & Orsillo, S. M.
- Affiliations
- University of Massachusetts Boston (US)
- Suffolk University (US)
- Corresponding author
- Fuchs, Cara
- Venue
- Cognitive and Behavioral Practice
- Publisher
- Elsevier BV
- Published
- 2013-02
- Volume
- 20
- Issue
- 1
- Pages
- 1-12
- ISSN
- 1077-7229 (ISSN-L)
- PMC
- PMC4539954
- OpenAlex
- W2318050465
- Semantic Scholar
- 022b762fad888682a22abddfcd36eac06d1c26c4
- Cited by
- 139
- References
- 90
- Citations by year
- 2026: 5 · 2025: 9 · 2024: 18 · 2023: 18 · 2022: 14 · 2021: 8 · 2020: 7 · 2019: 12 · 2018: 11 · 2017: 14 · 2016: 7 · 2015: 6 · 2014: 4 · 2013: 4 · 2012: 2
- FWCI
- 5.79
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Cognitive and Behavioral Practice (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R01MH074589)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Sociology and Political Science › Cultural Competency in Health Care
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- mindfulness-based interventions, acceptance and commitment therapy, culturally responsive treatment, cultural competence, marginalized communities, treatment acceptability, treatment efficacy, effect size, meta-analysis
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