CBT 2 (Cultural Considerations
Collaborative empiricism a challenge?
- Collaborative empiricism a challenge?
- Some literature suggests that client takes a passive role as probably would with their traditional expert e.g. a guru or healer
- Snag: an overtly directive style could result in patient viewing therapist as a controlling (agent of dominant culture)
- Asian patietns may prefer a more structured and prescriptive approach (Iwamas, 1993)
- Exploration of opinions about problem may lead to doubts about clinician's competence
- Challenges include "need for a quick fix"
Time and pacing
- Flexibility in session structure and agenda setting
- Collaboration on therapy focus and agenda setting (with sensitivity i.e. use of culture appropriate stories to emphasise key concepts)
- Building trust will involve therapist being “tested” – to see if patient was not being treated just as another number
- Emphasis on first impressions
Transition from consultative to collaborative empiricism
- South Asian Muslim cultures respect and trust a paternalistic attitude of their therapist
- Clear agreed summary of first session with a brief outline of key issues/plan to deal with them
- Setting task collaboratively (in-between session task), be mindful of extended family where available and the impact of your activity
Adapting CBT to a client's culture
- Without sensitivity to cultural norms and expectations of phenomenon, culture could create obstracles in the cognitive and behaviour change process, especially if the explanations used for change do not agree with cultural models
- Concepts of "self and the collectivist cultures" the self is defined in terms of group-identity and interdependence with group members (Owusu-Bempah, 2002)
- Group goals have primacy over individual goals
Needs: emphasis is on the needs of the group they belong to. In contrast the INDIVIDUALIST...
Culture & Emotions
- Individualism is the possible contributor of a range of emotional & behavioural issues in western cultures (Elliot, 2009)
- Self-focus can result in negative feelings & reduced ability to problem solve
- Self is celebrated/ individual accomplishment etc..
- In contrast, collectivism are family & community oriented
- There is interdependence (support from one another)
- Afro-Caribbean may revert to patois or Creole in situations they feel misunderstood.
- BAME – use of interpreters
- Consistency needed when using interpreters/ briefing them prior to therapy session to clarify their role
- Language barriers result in high healthcare costs (Bischoff &Denhaerynck, 2010)
Developing a Language
- Your speech can reflect your attitudes and beliefs you hold about other cultures
- Your language will betray you if you do not genuinely respect your client’s culture
- Care is therefore needed in its usage
- Thinking affects your language outside the therapy relationship
- Reflect on which words you use when describing people from cultures different from your own.
Identifying an appropriate interpreter
(Fear & Farooq, 2009)
- Consider language
- Education & patient’s literacy levels
- Migratory hx/ political context
- Allow for up to 15min briefing/review
- Intro/ purpose of meeting
- Requesting general cultural info
- You expect everything said in session to be interpreted verbatim
- Seeking clarification from therapist if they don’t understand something
- Sitting arrangements
- Speak directly to the patients (observe/ look out for non-verbal cues)
- Use short sentences/ allow for enough time for your interpreter to interpret
- Check for understanding
- Avoid jargon & sarcasm
Interpretation vs Translation
- Interpreation: the translation of a passage into another language, conveying the meaning of the original
- Translation: the substitution of the words of a passage in one language for the equivalent words in another language
Gender issues to consider
- Muslim women may feel uncomfortable when alone with the opposite gender
- Don’t shake hands, unless the patient initiates it
- Some patient may avoid prolonged eye contact out of respect and modesty
- Women may not be seen as authority figures by South Asian
Muslim cultures- this can impact on engagement
- In African Caribbean communities women felt need to be emotionally strong and cannot afford to show vulnerability
- Issues with decision-making traditionally left to husband within South Asian Muslim groups
Role of Family & Support “Asians look after their own”
- The stereotype of the extended Asian family, which is able to provide emotional support to its members is not borne out by evidence collected among people of Asian origin living in the UK.
- Role of family and extended community needs defining
- There is a strong sense of responsibility and obligation to the family (link to collectivist culture)
- We have the duty to recognise cultural differences and diversity within the systems in which we work, including our own profession.
- Insofar as “competence” is an aspect of professional integrity, then competence in dealing with diversity should be emphasised.
- Humility and flexibility and willingness to ask questions, thus become critical aspects of professional integrity.
Therapist Cultural Awareness
- To make sure cultural awareness is incorporated into therapy:
- Listen carefully to understand the importance of a client’s culture
- Consider ways in which a client’s culture influences conceptualisation and treatment planning.
- Read books and articles that educate about different cultures.
- Consult with colleagues who have cultural expertise.
- Discuss culture with clients. Seek feedback on cultural assumptions of the therapy and its procedures
Definition of Cultural Adaptation
What happens to validity if you change an intervention to adapt it to BME groups; is it feasible to adapt an intervention to all different groups ?
- The systematic modification of an CBT or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values.
§ (Bernal, Jiménez-Chafey, & Domenech Rodríguez, in press)
- The following have developed frameworks of integrating cultural issues in EBT -: Bernal & Santiago, 2006; Berrera & Castro, 2006; Hwang, 2006; Hall, 2001; Whaley & Davis, 2007)
What are Cultural adaptations?
- Changes or modifications to treatmetn or process that include the following:
- Additions, enhancement, or deletions
- Alterations to treatment components
- Changes in the intensity of the intervention
- Cultural or other contextual modifications
Types of Adaptations
- Surface or superficial modifications
- Translation of CBT
- Ethnic Matching (therapist/patient)
- Practical level (setting)
- Technical Adjustments (therapeutic techniques)
- Core Modifications
- Theoretical and philosophical considerations
- Consider cultural values, norms, beliefs etc.
Process of Adaptation
1 Information gathering
2 Producing guidelines for adaptation
3 Translation and adaptation of therapy material
4 Field testing the adapted therapy
- The combination of (emic and etic) perspectives we adopt, assumes that while the behaviours targeted by the intervention are exhibited across cultures, how people understand those behaviours and how willing they are to engage in the process of therapy to change the problematic behaviour may differ by cultural groups
§ (Domenech-Rodríguez & Wieling 2004).
Is There an Impact of Culture?
Culture significantly impacts on all aspects of psychosis- commencement, psychopathology, course, treatment appraches and outcomes
Culture and Psychosis
- Prevalence varies across the world (Selten et al., 1997; Jackson et al., 2007) and within countries (Kirkbride et al., 2006)
- e.g. perinatal care, mothering styless, family expectations and policy (one child policy), trauma, family support (protective), views re hallucinogenic substances, cultural beliefs, grief, guilt and shame
Culture and Presentation
- Presentations of psychosis in developing countries can be more acute, more florid positive symptoms, more catatonia with a shorter duration than in western societies such as Europe or North America.
- Duration of untreated psychosis (DUP) is also different in the way it is dealt within different cultures – illness models
- Often there is a recognition of psychopathology - attributions to illness and help seeking behaviour pathways may vary among cultures
- Example: Traditional Yoruba healers in Nigeria distinguish a wide variety of psychological abnormalities which bear close parallels to Western systems of classification.
- Content of hallucinations and delusions can be culturally influenced. Examples:
- India: The delusional content seems to have prominence of religious and supernatural delusions. Delusions of possession can be prominent in rural settings where clients feel they have been possessed by the goddess
- South Asian Muslims: Predominantly religious delusions, conspiracy and supernatural
- West Africa: The delusional content has changed slowly:
approx half in relation to the ancestors and similarly in relation to conspiracies or witchcraft including delusions of possession
- China: Changed relatively less over the past few years and currently perhaps half are estimated as linked to possession by spirits of the ancestors, some to conspiracy theories and a significant proportion were encountered as erotomanic or delusions of jealousy.
Therapeutic Process of CBTENGAGEMENT
- There is a strong focus on individualised engagement of the patient.
- Assessment is based on clinical practice
- Emphasis is placed on the here and now
- Information on current beliefs and how they
were arrived at is assembled into a formulation
- Specific approaches are used to address distress caused by depression
- Relapse Prevention and relearning then discharge/ Follow- up with booster session
Cultural ConsiderationsPre- engagement
- adjustments -client aligned to relevant culture
- Trust (to be earned) rather than assume it is a given.
Consider collaborative work with respected community members e.g. their elders
- Safe/ comfortable environment (location &
Assessment timing); Acculturation stress
- Normalization using relevant cultural metaphors
- Consider ethno-cultural & religious groups, etc..
- Consider adaptations to three levels of thought
- Relapse Prevention and relearning then discharge/ Follow- up with booster session
- Identification of emotions is central to the cognitive model
- BME groups in particular South Asian, emotional &cognitive reactions may not be spontaneously expressed.
- How do we overcome this barrier?
- Focus on somatic symptoms and use problem solving strategies early on in therapy.
- Re-labelling or reframing of organic symptoms into psychological terminology maybe more acceptable 64 as the rapport develops
- Understanding cultural background and linking it in formulation
- Traditional and cultural beliefs/practices
- use of diagrams to help understand formulations draw in cultural beliefs/experiences
- Assessing acculturation stage as demonstrated by the next figure
Cultural FormulationCultural Identity
Cultural reference group (s)
- Ethno-cultural & religious groups pt self-identifies +parents’ background
- Language i.e. spoken, at home, literate in
- Cultural factors in development
- Involvement with host culture (experience wth/r)
- Explanations of illness (idioms of distress/origin & host culture)
- Help-seeking pathways & behaviours
- Cultural factors (Psychosocial/current political ...MIGRATION)
Adapting CBT to a clients’ culture
- Beliefs, behaviours, emotional and even physiological responses to situations vary depending on the cultural background of the client.
- Consider the three levels of thought:
- automatic thoughts, underlying assumptions and core beliefs.
- The cognitive model of Panic, for example, suggests that panic is triggered by catastrophic misinterpretations of bodily and mental sensations.
- To date studies suggest that this model fits all cultures but the content of the catastrophic thought may vary. For example, a European man with a rapid heart rate may panic following the thought that “I’m having a heart attack.” A Chinese man on the other hand may panic following the thought that "I'm being haunted by an evil spirit" --> so which man is delusional?
- Core beliefs or schemas are strongly influenced by culture.
- In western cultures predominant schema values individualism (Owusu-Bempah, 2002).
- Consistent with this schema, children are taught to contribute to classroom discussions, seek recognition for individual achievement and express opinions.
- In the East things are seen differently, as these behaviours would be considered as rude because the predominant schema is being part of a group [collectivism].
- Eastern students are silent until the teacher expresses an opinion, achievement is attributed to the group and individuals try to become as similar to others as possible
- If someone approaches you with direct eye contact and a smile then the Western assumption is that this person is friendly.
- South Asian Muslim women may avoid eye contact out of respect.
- African-Caribbeans are very expressive and use gestures (watch them play a dominos game)
- They may revert to Patois or Creole
- It is important for Therapists to be familiar with cross-cultural differences in underlying assumptions; otherwise they may view client’s beliefs as idiosyncratic when they are, in fact normative in the client’s culture
- Use of strategies such as validation, acceptance, and non-judgemental
- Problem solving- exploring pros & cons of behaving in a certain way
- Capacity to challenge and modify dysfunctional assumptions, creating doubt & considering alternative views
- Mindfulness based approaches may be appropriate for South Asian groups as origins derive from eastern practices –primarily Sufist and Buddhism influences
Cultural relevant themes to consider
- Spirituality and Religion
- Immigration nstressors
- Experience of prejudice
- Discrimination / cultural identity
- Acculturation stresses
- Access to services stressors/poverty and financial stressors
Spirituality & Religion
- Spirituality: fluid; belief at a personal level
- Spiritual development is a vital part of Asian cultures (Laungani, 2004)
- Defined as “an aspect of human existence that gives its humanness” …includes such vital dimensions as quest for meaning, purpose ….(Swinton, 2001)
- Religion: organised; way of life; belief in a transcendent being
- Works as a coping strategy, social support & networks, Locus of control
- Islamic view: some aspects of life (life & death) are predetermined (taqdeer) and others are under an individual’s control
- Blocks: clinician ignorance or interpreting spiritual experiences as manifestations of psychopathology
- Lack of confidence
- When faced with the subject of religion and spirituality therapist feel disempowered
- Traditional view - A group of people characterized by
certain physical features
- Geographic race – A human population that has inhabited a certain geographic area sufficient long to develop distinctive genetic composition
- Current view - DNA analysis showed that there are greater variations within racial groups than among them.
- Socially and culturally constructed categories that may have little to do with actual biological differences.
- Social discrimination, even persecution, may take place between people of different races.
- Social groups that distinguish themselves from other groups by a common historical path, behaviour norms, and their own group identities.
- The members of an ethnic group are affiliated and may share a common language, religion, culture, racial background, or other characteristics that make them identifiable 'With their own group.
- Ethnicity is transactional, shifting and essentially impermanent. It signifies allegiance to the culture of origin and implies a degree of choice which ‘race’ precludes. Ethnicity is part of everyone's identity.
- A set of guidelines inherited by members of a particular society that tell them how to view the world, how to experience it emotionally and how to behave in relation to other people (Helman, 2000)
- The core of culture is value system
- It is real, symbolic and transmitted through beliefs, mythology, religion, art, rituals and language etc.
- Can be both resilient and fragile
Rationale for CaCBT in the UK
- Recent 2011 census revealed a 2.5 million increase in BME figures resulting in an estimated 7.1 million BME population in UK (ONS, 2011).
- Patients from ethnic backgrounds likely to be misunderstood and misdiagnosed, more likely to be compulsorily detained (53.9% -2008/9
(Fernando, 1988; Mental Health Bulletin, 2009)
- Higher rate of involuntary admissions and dissatisfaction with the services among this group (Bhugra, 1997; Bhui, 1998; ONS, 2008; Keating, 2005).
- Less likely to have their social and psychological needs addressed within the care planning process (Bhui, 2002)
- NICE, 2002,2009, 2014; APA, 2002
Psychological Treatments: Argument for
- Stereotyping - "hostile, impulsice and not psychologically minded" (Sabshin et al., 1970)
- Difficulty in engaging these patients adequately (Rosenthal and Frank, 1958)
- Perceptions and attitudes of the professionals (Byford et al., 2001)
- European culture civilised - historical assumptions (Thomas and Sillen, 1972; Lewis, 1965)
- Lower referral rates fo psychological treatment in BME groups
- Culturally diverse illness models and cognitions (McCabe and Priebe, 2004; Rathod et al., 2010)
Efficacy of CBT
- Sensky et al. (2000) RCT of CBT for medication-resistant schizophrenia
- CBT was found to be superior to Befriending in managing negative symptoms (Turkington et al. 2008)
- CBT effective when used in conjunction with family interventions (Pilling et al., 2002)
- Insight into schizophrenia study (Rathod et al., 2005) replicated the previously stated (Turkington et al., 2002) superiority of CBT.
- Relapse reduction (Garety et al., 2008)
- Social functioning (Startup et al., 2004) CBT potentially a cost effective intervention for people with acute psychosis or med-resistant schizophrenia
- Grant et al. (2011) effective in treating (76 studies) d=.45
Criticism of CBT
- Eurocentrism of CBT theory
- Emphasis on rational thinking can be interpreted in ways that devalue Asian Muslim spirituality and tendencies towards emotional expressiveness
- Enforcing dominant cultural values (individualistic concept)
- Responsibility and self-determination
- The assumption that CBT is neutral and universally applicable due to its scientific orientation is challenged (Sue, 1999)
- Lack of generalisability of findings and limited numbers of BME in evidence-based trials
Laungani (2004) suggests four core value dimensions that distinguish Western & Asian cultures:
- Cognitivism- emotionalism
- Free will- determinism
- Materialism- spiritualism
- If there are systematic differences in the empirical connections between symptoms, disorders, race, ethnicity etc, then failure to consider then will result in poor outcomes (Alegria & McGuire, 2003)
Traditional view of self-disclosure based on the Freudian concept that purts psychoanalysts to be: "impenetrable to the patient... reflect nothing but what is shown to him" (Freud, 1914)
Clinical Implications for Self-disclosure
- 1st impressions count-when asked to disclose personal details, be aware of your behaviour & attitude.
- hesitation to respond & a defensive stance could have implications in your rapport
- Be aware of culturally derived behaviours, beliefs and attitudes
- Be sensitive in your response when working with BME groups with elevated levels of mistrust.
- Elements of self-disclosure & warmth can build trust and also give the feeling of being respected as equals.
- Training & development for clinicians on effective ways of applying self-disclosure with diverse clients
- Further investigation on the efficacy of disclosure and managing risk factors in varied settings
The need to understand one’s own culture
- It is important for every individual to recognise their own culture and how they are shaped by it as it provides the individual with a frame of reference and an identity both culturally and racially.
- This undoubtedly will consciously or unconsciously have an influence on one’s interactions and relationships between one’s own and others culture.
What is the role of immigration distress?When you assess someone you should consider these things
- From country of origin to host country – a journey that can be fraught with danger!
- Why might one decide to migrate?
- Pre-immigration stressors?
- What are the risk factors associated with this phenomenon?