Culturally responsive cognitive-behavioral therapy, PA Hays, GY Iwamasa

Tags: American Psychological Association, Washington, DC, New York, Guilford Press, Asian Americans, psychology, American Counseling Association, clients, cognitive-behavioral therapy, client, environment, environmental conditions, Harvard Medical School, American Psychiatric Association, cognitions, Pamela A. Hays, mental health, Counseling, cognitive restructuring, African Americans, University of Washington, environments, problem solving, American Indians, John Gonzalez, State University, Counseling & Development, Monitor on Psychology, Cross-cultural communication, Greenwood Press, University of British Columbia Press, P. Pedersen, cognitive aspects, Charles C Thomas, Ethnicity and family therapy, prejudice and discrimination, Cognitive-behavioral treatment, Evidence-based practice, Prince, S. E., American Psychologist, Journal of Multicultural Counseling & Development, PAMELA A. HAYS Waxier-Morrison, Padesky & Greenberger, cultural environment, PAMELA A. HAYS Beck, cultural perspective, dysfunctional thoughts, behavior therapy, attention, PAMELA A. HAYS Lee, cultural perspectives, dominant culture, borderline personality disorder, health professionals, cultural identities, maladaptive behavior, social environments, environmental problems, Seattle Justin Douglas McDonald, Stanford University School of Medicine, Cheryl M. Paradis, Steven A. Safren III, Colorado State University, Rebecca P. Cameron, Brooklyn Steven Friedman, culturally diverse, Steven Friedman, University of California, Neuropsychiatric Institute, Pamela A. II. Iwamasa, Boston Kristen H. Sorocco, RICHARD M. SUINN, Rutgers University, Fairbanks Pamela A. Hays, Christopher R. Martell, Azusa Pacific University, private practice, Gayle Y.Iwamasa, Richard M. Suinn Acknowledgments, Social Science Data Analysis Network, Asian American, Daniel Cukor, Fort Collins Junko Tanaka-Matsumi, Antioch University, University of North Dakota, University of Oklahoma Health Science Center, Linda R. Mona, Angela W. Lau, United States Copyright Act of 1976, Shalonda Kelly, United Book Press, Inc., University of Alaska, Curtis Hsia, Boston Curtis Hsia, Sacramento Veronica Cardenas, Gayle Y. Iwamasa, Kwansei Gakuin University, DePaul University, Kimberly F. Balsam, Anchorage Devon Hinton, British Library, Los Angeles Christopher R. Martell
Content: CULTURALLY RESPONSIVE COGNITIVE-BEHAVIORAL THERAPY Assessment, Practice, and Supervision Edited by Pamela A. Hays and Gayle Y. Iwamasa American Psychological Association Washington, DC
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Culturally responsive cognitive-behavioral therapy : assessment, practice, and supervision / edited by Pamela A. Hays and Gayle Y.Iwamasa. p. cm. Includes bibliographical references and index. ISBN 1-59147-360-8 1. Cognitive therapy. 2. Behavior therapy. I. Hays, Pamela A. II. Iwamasa, Gayle.
RC489.C63C85 2006 616.89'142--dc22
British Library Cataloguing-in-Publication Data A CIP record is available from the British Library.
Printed in the United States of America First Edition
Richard M. Suinn
Introduction: Developing Culturally Responsive
Cognitive-Behavioral Therapies
Pamela A. Hays
I. Cognitive-Behavioral Therapy With People of Ethnic
Minority Cultures
Chapter 1. Cognitive-Behavioral Therapy With
American Indians
Justin Douglas McDonaldand John Gonzalez
Chapter 2. Cognitive-Behavioral Therapy With Alaska
Native People
Pamela A, Hays
Chapter 3. Cognitive-Behavioral Therapy With Latinos
and Latinas
KurtC. Organista
Chapter 4. Cognitive-Behavioral Therapy With
African Americans
Shalonda Kelly
Chapter 5. Cognitive-Behavioral Therapy With Asian
Gayle Y. Iwamasa, Curtis Hsia, and
Devon Hinton
Chapter 6. Cognitive-Behavioral Therapy With People
of Arab Heritage
Nuha Abudabbeh and Pamela A. Hays
Chapter 7. Cognitive-Behavioral Therapy With
Orthodox Jews
Cheryl M. Paradis, Daniel Cukor,
and Steven Friedman
II. Cognitive-Behavioral Therapy With People of Additional
Minority Cultures
Chapter 8. Cognitive-Behavioral Therapy With
Culturally Diverse Older Adults
Angela W. Lau and Lisa M. Kinoshita
Chapter 9. Cognitive-Behavioral Therapy and People
With Disabilities
Linda R. Mona, JenniferM. Romesser'Scehnet,
Rebecca P. Cameron, and Veronica Cardenas
Chapter 10. Affirmative Cognitive-Behavioral Therapy
With Lesbian, Gay, and Bisexual People
Kimberly F. Balsam, Christopher R. Martell,
and Steven A. Safren
III. Assessment and Supervision Issues
Chapter 11. Cultural Considerations in Cognitive-
Behavioral Assessment
Sumie Okazaki and Junko Tanaka-Matsumi
Chapter 12. Multicultural Cognitive-Behavioral Therapy
Gayle Y. Iwamasa, ShilpaM. Pai, and
Kristen H. Sorocco
Author Index
Subject Index
About the Editors
CONTRIBUTORS Nuha Abudabbeh, PhD, Court Services and Offender Supervision Agency for the District of Columbia, Washington, DC Kimberly F. Balsam, PhD, University of Washington, Seattle; private practice Rebecca P. Cameron, PhD, California State University, Sacramento Veronica Cardenas, PhD, Sharp Mesa Vista Hospital, San Diego, CA Daniel Cukor, PhD, State University of New York Downstate Medical Center, Brooklyn Steven Friedman, PhD, ABPP, State University of New York Downstate Medical Center, Brooklyn John Gonzalez, PhD, University of Alaska, Fairbanks Pamela A. Hays, PhD, Central Peninsula Counseling Center, Kenai, AK; Antioch University, Seattle, WA; University of Alaska, Anchorage Devon Hinton, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston Curtis Hsia, PhD, Azusa Pacific University, Azusa, CA Gayle Y. Iwamasa, PhD, DePaul University, Chicago, IL Shalonda Kelly, PhD, Rutgers University, Piscataway, NJ Lisa M. Kinoshita, PhD, Stanford University School of Medicine, Stanford, CA Angela W. Lau, PhD, University of California, Neuropsychiatric Institute and Hospital; private practice, Los Angeles Christopher R. Martell, PhD, ABPP, private practice; University of Washington, Seattle Justin Douglas McDonald, PhD, University of North Dakota, Grand Forks Linda R. Mona, PhD, Veterans Affairs, Long Beach Healthcare System, Long Beach, CA Mil
Sumie Okazaki, PhD, University of Illinois at Urbana-Champaign Kurt C. Organista, PhD, University of California, Berkeley Shilpa M. Pai, PhD, University of North Carolina at Pembroke Cheryl M. Paradis, PsyD, State University of New York Downstate Medical Center, Brooklyn; Marymount Manhattan College, New York, NY Jennifer M. Romesser-Scehnet, PsyD, Rancho Los Amigos National Rehabilitation Center, Downey, CA Steven A. Safren, PhD, Massachusetts General Hospital, Harvard Medical School, Boston; Fenway Community Health, Boston Kristen H. Sorocco, PhD, University of Oklahoma Health Science Center, Oklahoma City Richard M. Suinn, PhD, Emeritus Professor of Psychology, Colorado State University, Fort Collins Junko Tanaka-Matsumi, PhD, Kwansei Gakuin University, NishinomiyaCity, Japan
FOREWORD RICHARD M. SUINN This volume fills a major gap in the clinical literature--a singularfocus on adapting cognitive-behavioral therapy (CBT) for people of diverse cultural identities. This goal is important for several significant reasons. First, despite the rapidly increasing numbers of culturally diverse people in the United States, there is a dearth of clinical materials on counseling or psychotherapy using CBT for such populations. The number of African Americans increased from 11.5% of the U.S. population in 1980 to 12.1% in 2000; Latinos/Latinas nearly doubled from 6,4% to 12.6%; Asian Americans rose from 1.5% to 3.6%; and American Indians and Alaska Natives increased from 0.6% to 0.7%. Whereas the number of European Americans increased by only 8% between 1980 and 2000, Asian Americans increased by 190%, Latino/Latinas by 143%, African Americans by 30%, and American Indians and Alaska Natives by 46% (Social Science Data Analysis Network, 2004; U.S. Census Bureau, 1983). As examples of data on nonethnic culturally diverse persons, it is estimated that about 14% of the New York area population is Jewish (Ukeles & Miller, 2004), individuals with disabilities comprise about 19% of the U.S. population, and about one in eight Americans is 65 years or older (Administration on Aging, 2000; Sotnik & Jezewski, 2005). Despite these significant numbers and despite the efficacy of CBT, very few clinically relevant articles are available regarding CBT applications to such populations. As Hays concludes in the Introduction, "despite its popularity and widespread use, the practice-oriented research on CBT has historically focused almost exclusively on people of European American identities" and "textbooks of CBT now cover a wide range of disorders, but none explicitly integrates cultural considerations throughout the text" (this volume, p. 5). This book is based on the recognition of the appropriateness of CBT for these particular cultural groups. Such populations often share histories of IX
discrimination or perceptions of being less than adequate; CBT is built on being nonjudgmental, on focusing on strengths, and on empowering clients. Many of these populations have cultural worldviews that are congruent with CBT approaches: a focus on the present, an expectation that healers and help givers will be prescriptive, and an awareness of the importance of the social context. CBT is also relevant for its educational orientation that not only avoids the stigma and shame sometimes associated with seeking help for psychological issues but also provides the client with a more readily understood conceptualization of the issues. The authors are experienced therapists and scholars as well as being themselves part of the various cultural groups. Using their combined knowledge of CBT and the various cultural norms, they provide concrete and practical advice for the reader. The writings identify important culture-specific variables essential for adapting CBT for each population, such as religion and spirituality concepts, racism and political history, linguistic levels and cognitive style, generation and immigration issues, family structure and gender role assignments, collectivistic orientations, and health belief viewpoints. One of the very special contributions of this volume is the down-to-earth and practical suggestions identified to merge such cultural characteristics with CBT practice, for instance, how to interpret behaviors that seem like denial from an older or Asian American or Orthodox Jewish client, or ways to increase motivation by changing from the individualisticWestern-oriented "you need to take care of yourself' to the collectivistic "you can take better care of your family by taking care of yourself." Case histories provide excellent examples of such integration, such as the case of Mr. Lopez, a Latino client experiencing severe back pain (chap. 3). In this one case history, the therapist shows awareness of respeto and personalismo in the initial encounter, offers a culturally adapted cognitive restructuring assignment, restores motivation through adopting familismo values, uses a culturally sensitive approach to set limits, and discusses a culturally appropriate approach to termination. The writings are not simply uncritical endorsements of CBT. Discussions include consideration of possible deficiencies in CBT's relevance for culturally diverse groups, such as the fact that CBT is not value neutral. For instance, the emphasis on reality testing of beliefs could conflict with the spirituality beliefs of some groups. Also, procedures such as assertiveness training could be at odds with the cultural values of respect for elders and the avoidance of confrontation. However, after identifying such potential deficiencies, the authors then offer advice on overcoming such problems through increasing cultural sensitivity in work with clients. Although the chapters and case examples may seem somewhat oriented to the cognitive approaches of CBT, careful reading will confirm that the materials cover other behavioral approaches such as parental training, behavioral couple therapy, exposure therapy, response prevention, self-monitoring, and behavioral rehearsal. The book is also unique in being inclusive
in its definition of cultural diversity. Hence there are chapters devoted to people with disabilities; lesbian, gay, and bisexual people; older adults; as well as Arab Americans and Orthodox Jews. This decision is a consequence of the recognition that shared cultural experiences are present within such groups, discriminatory experiences based on negative views of others exist, stigmatization is frequently associated with group membership, and despite the increasing numbers, the groups are often viewed as outside the norm. By broadening the target groups considered, this volume offers an enriched approach to enhancing counseling and psychotherapy procedures. Such coverage emphasizes the valid point that the therapeutic encounter demands sensitivity to the core belief system; normative behavioral background; and social, familial, and personal history of the "culture" of any client. This is a book that informs, conceptualizes, and advises about making CBT culturally responsive with details that make it essential reading for the practitioner. REFERENCES Administration on Aging. (2000). A profile of older Americans. Washington, DC: Author. Social Science Data Analysis Network. (2004). United States population by race. Retrieved October 2004 from Sotnik, P., & Jezewski, M. A. (2005). Disability service providers as culture brokers. In J. H. Stone (Ed.), Culture and disability: Providing culturally competent services (pp. 15-36). Thousand Oaks, CA: Sage. Ukeles, J., & Miller, R. (2004, October). The Jewish study of New York: 2002, Final report (Final text, exhibits and an expanded research note on methodology). New York: Ukeles Associates for UJA Federation of New York. U.S. Census Bureau. (1983). 1980 census of population. Washington, DC: U.S. Government Printing Office.
ACKNOWLEDGMENTS We would like to thank our editor Ed Meidenbauer and the excellent staff at the American Psychological Association, and especially Susan Reynolds for her encouragement of this book. Pam would like to thank Marjorie and Hugh Hays and Bob McCard for their support and helpful feedback. Gayle would like to thank Russell, William, and Robert Koch for their patience, understanding, encouragement, and support. We are both grateful to our professional mentors, supervisors, colleagues, clients, and students for all that they have taught and shared with us. xiu
INTRODUCTION: DEVELOPING CULTURALLY RESPONSIVE COGNITIVEBEHAVIORAL THERAPIES PAMELA A. HAYS Julia is a 35-year-old single mother of two teenage boys who came to see a therapist for anxiety related to her new job. She explained to the therapist that she had worked part time and attended school for over 10 years to reach her dream of becoming an occupational therapist (OT). After obtaining her degree, she was hired by a hospital with a large OT staff, and within 3 years she was promoted to department head. But since her promotion, the staff had become increasingly critical of her, and her supervisor had made several pejorative remarks about her qualifications. Julia was feeling a great deal of anxiety about their opinions of her, and although she knew that she waswell qualified, she was doubting her ability to do the job. She asked the counselor to help her find a way to decrease her anxiety and "not care so much what other people say or think about me." If you already use cognitive-behavioral approaches in your work, you probably read this example looking for the cognitive, behavioral, affective, and environmental components of Julia's complaints. In conceptualizing her difficulties, you may have hypothesized that some of Julia's anxiety stems from the newness of her position, the stressors inherent in supervisory work, or the social stressors of parenting two teenagers alone on one income. You may have inferred possible core beliefs and self-talk contributing to her anxiety and doubts. And you may have considered how specific cognitive- 3
behavioral strategies could help Julia. For example, problem-solving skills training might help her to resolve the conflicts with staff, cognitive restructuring could help to decrease her anxiety and self-doubt, and a coping skills group might provide her with additional social support. But what if you had been told that Julia is a 35-year-old Latino, single mother? Would this piece of information have raised some questions and hypotheses that you did not initially consider? For example, what are the ethnic identities of Julia's staff and supervisor, and could this have anything to do with their attitudes toward her? Could Julia's self-doubts emanate from experiences of prejudice and discrimination? Could there be language differences that might account for some communication difficulties? What opportunities, strengths, and supports might be available to Julia and her family, given their cultural heritage, identities, and contexts? Julia's ethnicity was initially omitted to make the point that when cultural information is not included, the assumption is often made that the client is of European American heritage, and as a result, potentially important questions and hypotheses are often overlooked. Such questions and hypotheses are important to consider with clients of any identity, even European American. Unfortunately, the omission of ethnic and cultural information is the rule rather than the exception in clinical and counseling research, including cognitive-behavioral therapy (CBT). This neglect is probably due in part to the cultural homogeneity of the field; approximately 85% of psychologists and 94% of American Psychological Association (APA) members are of European American heritage (APA, 2005; Dittman, 2003). In many cases, European American therapists may simply not perceive minority cultural influences because they do not have this experience or close relationships with people from whom they could learn. However, the dominance of European American perspectives and assumptions in CBT is not due solely to the disproportionate number of European American therapists. It is also related to the reinforcement of dominant cultural values and perspectives by the larger society, of which the field of psychotherapy is a part. Consider, for example, the social and therapeutic emphasis placed on assertiveness in social interactions (i.e., over subtlety), change (over patience and acceptance), personal independence (over interdependence), open self-disclosure (over cautious protection of one's family reputation; Kim, 1985; Pedersen, 1987; Wood & Mallinckrodt, 1990). CBT is currently the leading theoretical preference among psychologists today. Its effectiveness has been demonstrated in the treatment of anxiety (A. T. Beck, Emery, & Greenberg, 1985), depression (A. T. Beck, Rush, Shaw, & Emery, 1987), obsessive-compulsive disorder (Clark, 2004), chronic pain (Thorn, 2004), eating disorders (Cooper, Fairburn, & Hawker, 2003), marital conflict (Epstein & Baucom, 2002), substance abuse (A. T. Beck, Wright, Newman, & Liese, 2001), personality disorders (A. T. Beck, Free-
man, Davis, & Associates, 2003; Linehan, 1993), and many other problems (Barlow, 2001). However, despite its popularity and widespread use, the practiceoriented research on CBT has historically focused almost exclusively on people of European American identities (Hays, 1995; Iwamasa & Smith, 1996; Suinn, 2003). For example, in 1988, Casas reviewed psychological abstracts of the preceding 20 years, looking for studies of cognitive-behavioral treatment of anxiety in people of racial or ethnic minority groups. He found only three empirically based outcome studies, two of which had samples of only two persons each. Renfrey (1992) conducted a similar search for CBT studies involving Native American participants; his review of 11 major behavioral and cognitive-behavioral journals (from their beginnings to the end of 1990) yielded one case study of one Native American client. In a 1996 survey of the three leading behavioral journals, only 1.31% of the articles were found to focus on ethnic minority groups in the United States (Iwamasa & Smith, 1996). Overview textbooks of CBT now cover a wide range of disorders, but none explicitly integrates cultural considerations throughout the text (e.g., see J. S. Beck, 1995, 2005; Dobson, 2001; Ledley, Marx, & Heimberg, 2005; Greenberger & Padesky, 1995; Salkovskis, 1996). This neglect of culture in CBT occurs at a time when ethnic minority groups make up approximately 33% of the U.S. population (APA, 2002; U.S. Census Bureau,2000), and political changes have led to increasing numbers of immigrants and refugees internationally (Marsella, Bornemann, Ekblad, & Orley, 1994). Indigenous groups, people with disabilities, older adults, and gay, lesbian, and bisexual people have become more politically active and visible (Adelson, 2000; Olkin, 1999; Perez, DeBord, & Bieschke, 2000). With this diversity has come a growing body of research demonstrating how cross-cultural competence facilitates therapy and improvesassessment (e.g., see Dana, 2000; Pope-Davis & Coleman, 1997; D. W. Sue, 2001). The APA and the American Counseling Association have published guidelines calling attention to the importance of cross-cultural competence for therapists, educators, and researchers (APA, 2000a, 2000b, 2002, 2004; Roysircar, Arredondo, Fuertes, Ponterotto, & Toporek, 2003). And the Surgeon General's report on mental health in the United States clearly states the need for culturally competent services that address both the uniqueness of the individual and culturally related influences (U.S. Department of Health and Human Services, 1999). During the past 15 years there has been an enormous increase in the number of books addressing ethnic and cultural minority groups, including those by Aponte, Rivers, and Wohl (1995); Comas-Diaz and Greene (1994); Fong (2004); Hays (2001); Ivey, Ivey, and Simek-Morgan (1997); C. C. Lee (1997); McGoldrick, Giordano, and Pearce (1996); Mio and Iwamasa(2003); Paniagua (1998); Pedersen, Draguns, Lonner, and Trimble (2002); Pipes McAdoo (1999); Robinson and Howard-Hamilton (2000); Smith (2004);
and D. W. Sue and Sue (2002). Texts have also been written on counseling children of color (Johnson-Powell & Yamamoto, 1997); diverse gay, lesbian, and bisexual people (Martell, Safren, & Prince, 2004; Perez et al., 2000); and people of diverse religious and spiritual faiths (Burke & Miranti, 1995; Fukuyama & Sevig, 1999; Miller, 1999; Shafranske, 1996). In addition, a number of multicultural counseling books have been published regarding specific ethnic groups, including African Americans (Bass, Wyatt, & Powell, 1982; Boyd-Franklin, 2003); Asian Americans (E. Lee, 1997; Uba, 1994); American Indians and Alaska Natives (Droby, 2000; Herring, 1999; Swan Reimer, 1999;Swinomish Tribal Community, 1991); Latinos and Latinas (Falicov, 1998); Arab people (Dwairy, 1998); English-speaking West Indians (Gopaul-McNicol, 1993); and ethnic minority groups in Canada and Australia (Pauwels, 1995; Waxier-Morrison, Anderson, &. Richardson, 1990). The fact that this list is not comprehensive underscores the exceptional growth in this area. However, despite the growth, multicultural researchers have been slow to consider cognitive-behavioral interventions. The lack of cross-pollination between the fields of CBT and multicultural therapy (MCT) is surprising for several reasons. First, a recent study indicates that CBT and MCT are the top two trends in psychotherapy today (Norcross, Hedges, & Prochaska, 2002). With such a proliferation of research in each area, one would expect to see more overlap between them. Second, CBT and MCT share a number of basic premises. Both emphasize the need to tailor therapeutic interventions to the unique situation of the individual. Both emphasize the empowerment of clients--MCT through its affirmation of clients' cultural identities, and CBT through recognition of each client's expertise regarding his or her own needs and situation. Both MCT and CBT also emphasize attention to the therapeutic aspects of clients' strengths and supports. Third, increased interest in evidence-based practices has called attention to the dearth of empiricallybased studies involving people of minority cultures (Hall, 2001; S. Sue, 2003). The empirical orientation of CBT makes it well suited for such research although, at the same time, it is important to recognize that evidence-based practices also include some broader approaches to research evidence such as clinical expertise and patient values (Levant, 2005). Fourth, the CBT field has a great deal to gain from cross-cultural research. Culturally sensitive attempts to understand how CBT works and does not work with minority populations offer a multitude of opportunities for CBT researchers to challenge, expand, and refine their theories. Such work could lead to creative approaches that help a much wider range of people. Recognizing such possibilities also requires a consideration of the potential limitations of CBT with minority cultures. For example, CBT is often assumed to be value-neutral because of its reliance on the scientific method.
However, CBT is as value-laden as any other psychotherapy. Its emphasis on cognition, logic, verbal skills, and rational thinking strongly favors dominant cultural perspectives including definitions of rationality (Kantrowitz & Ballou, 1992). This cognitive emphasis can easily lead to an undervaluing of the importance of spirituality. In addition, CBT's focus on changing oneself can contribute to the neglect of cultural influences that restrict a person's ability to create and implement change. This internal focus, if not balanced by a behavioral perspective that recognizes the power of environmental influences, may contribute to blaming the client for problems that are primarily environmentally based. However, such limitations are not insurmountable, and figuring out ways to address them is part of the process of making CBT more responsive to people of diverse cultural identities.
COGNITIVE-BEHAVIORAL THERAPY: AN OVERVIEW In the 1950s and early 1960s, the field known as behavior therapy called attention to the ways in which environments could be manipulated to elicit, shape, and reinforce desired behaviors. A number of behavioral researchers subsequently became interested in the influence of cognition on behavior, and it was out of this interest that the field of CBT developed. CBT involves a consideration of five components to any problem: cognition (thoughts), mood (emotions), physiological reactions (e.g., physical sensations and symptoms), behavior, and the environment (Padesky & Greenberger, 1995). CBT presumes that cognitions (which include perceptions, beliefs, and self-talk) mediate one's mood, behavior, andphysiological reactions in response to the environment (Beck, 1995). Dysfunctional cognitions are believed to contribute to maladjustment, whereas functional cognitions contribute to healthy adjustment (Dobson, 2001, p. 27). It is the role of the cognitive-behavioral therapist to help clients become aware of the relationships between these five areas. Clients learn to recognize how certain negative, unhelpful, or unrealistic thoughts can generate distress in the form of uncomfortable physical sensations, maladaptive behavior, and emotions that feel uncontrollable or out of proportion to the situation. Clients also learn that social and physical aspects of one's environment can contribute to their distress.Once the client understands these connections, the therapist helps the individual to develop more helpful coping strategies, which can be divided into three main categories (Dobson, 2001): (a) problem solving, (b) social skills and support, and (c) cognitive restructuring. As the three categories suggest, clients may need to take concrete action to solve the problem, learn new social skills to improve their social environments and ability to solve problems, or develop a broader network of support to counteract the negative effects of environmental stressors. In ad-
dition, clients learn that there is always the possibility of changing the way they feel by changing the way they think, that is, cognitive restructuring. The strategy of cognitive restructuring involves more than simply thinking positively (Padesky & Greenberger, 1995). Rather, clients learn to recognize common cognitive errors, automatic dysfunctional thoughts, and cognitive tendencies related to the schema (a sort of cognitive template) by which human beings take in and organize their experience. By considering a broader range of possible interpretations of events and beliefs that one may never before have considered, clients learn to see themselves, the world, and the future more fully and realistically (Beck, 1995; Beck et al., 1987; Padesky & Greenberger, 1995). Making CBT More Culturally Responsive A culturally responsive approach to CBT begins long before the start of one's therapeutic work with clients. It begins with therapists' attention to those areas in which they may hold biases because of inexperience or knowledge gaps. It may be helpful to think of a lack of knowledge and inexperience (otherwise known as ignorance) as creating a sort of hole or vacuum inside of us. We all know what happens in a vacuum: It sucks in whatever surrounds it to fill itself up. In the case of a lack of experience or knowledge regardinga whole group, the vacuum becomes filled with dominant cultural messages that bombard us every day yet are so subtle and pervasive that we often do not notice them. We then use this information, often without awareness, to make generalizations and draw conclusions about members of particular groups (Hays, in press). What is important to recognize (and it keeps us humble) is that we all have these little vacuum packs of ignorance regarding various groups. The first step is to begin to recognize them. Only then can we actively work to replace our inaccurate beliefs and assumptions with reality-based information. This type of work is personal, and it cannot be accomplished in one course or even in several cross-cultural encounters. Rather, it is an ongoing process that involves exploring the impact of cultural influences on one's own beliefs (i.e., cognitions), behaviors, and identities. Once a commitment to this personal work is made, it can befacilitated by the following activities: obtaining cultural information from culturespecific sources (e.g., news published by ethnic and other minority communities themselves); attending cultural celebrations and other public events; obtaining supervision from a person who belongs to and is knowledgeable about a minority culture; consulting with a culturally diverse professional group; reading from the wealth of multicultural counseling research now available; and developing relationships with people of diverse cultures.Engagement with these forms of learning facilitates the development of the cognitive schema or template into which client-specific information can be
considered and incorporated. The development of this cultural schema is the responsibility of the therapist. That is, clients should not be expected to educate the therapist about the broader social and cultural meanings of their identities. However, the therapist will need to obtain information from clients regarding each client's unique personal experience of their culture. Cognitive-Behavioral Assessment One of the first steps in a cognitive-behavioral assessment involves conceptualization of the problem. CBT divides problems into two general categories. The first category consists of problems in the client's environment (e.g., a difficult task, a conflict, or a stressful situation) that imply an environmental solution (e.g., changing the task, obtaining help, or decreasing stressors in the situation). The second category consists of problems that are more internal, namely, those involving dysfunctional cognitions and undesirable overwhelming emotions. Difficulties in this second category are commonly referred to as cognitive problems. Many problems involve both environmental and cognitive elements, but distinguishing between the two is important in developing the most effective intervention. environmental problems One would think that cultural influences would be included in the definition of any environment, but this has not been the case with CBT. Cultural aspects of clients' environments have often been overlooked or framed in negative terms. A culturally responsive assessment takes into account both positive and negative aspects of clients' cultural environments (Hays, 1996a, 1996b). Culturally related stressors (i.e., the negative aspects) have been elucidated in Axis IV of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). This list of psychosocial and environmental problems includes difficulties such as acculturation; discrimination; living in an unsafe neighborhood, in inadequate housing, or extreme poverty; receiving insufficient welfare support; inadequate health care or social services;legal problems;and exposure to disastersor war(American Psychiatric Association, 2000). Positive aspects of a person's cultural environment have received much less attention. These positive aspects can be considered in two categories: environmental conditions and interpersonal supports (Hays, 2001). Environmental conditions may be natural or constructed. Examplesof natural conditions include rivers, beaches, and land available for subsistence and recreational fishing, hunting, gardening, and farming. Constructed environmental conditions may be an altar in one's home or room to honor deceased family members, a space for prayer and meditation, availability of culturally preferred foods, the presence of culture-specific art and music, a
place for animals, and communities that facilitate social interaction (e.g., villages where homes are within walking distance of one another). Interpersonal supports include extended families (blood related and nonblood related), religious communities, traditional celebrations and rituals, recreational activities, storytelling activities that pass on the history of a group, and involvement in political and social action groups. Having a child who is successful in school can also be an important source of pride and strength for parents and extended family. The explicit consideration of these positive aspects of cultural environments is important for a number of reasons. For one, helping clients to recognize culturally related supports clearly communicates respect for a client's cultural heritage. Respect is a central concept among many people of minority cultures, and as such it is important for the purposes of establishing a good working relationship (Boyd-Franklin, 2003; El-Islam, 1982; Kim, 1985; Matheson, 1986; Morales, 1992; Swinomish Tribal Community, 1991). Second, cognitive-behavioral research encourages the incorporation of strengths and supports in the development of effective therapeutic interventions. The use of naturally occurring supports works precisely because the supports are naturally occurring and thus easier to implement and maintain. The explicit consideration of culturally related environmental conditions and supports opens up an array of interventions that might otherwise be overlooked from a dominant cultural perspective. When investigating cultural supports, it is essential to consider the client's personal orientation to his or her culture of origin and to the dominant culture (i.e., competence in each culture). LaFromboise, Coleman, and Gerton (1993) described five models that have been used to explain the psychological processes, social experiences, individual challenges, and obstacles to competence in two cultures: assimilation, acculturation, alternation (i.e., between the two cultures), multicultural, and fusion. In recent years, acculturation has received a great deal of attention, with the concept initially conceptualized as a linear process consisting of two main categories: acculturated and unacculturated/traditional. However, researchers now recognize that acculturation involves a much more complex process that can include a variety of unique adaptations of beliefs, behaviors, and practices (Chun, Balls Organista, & Marin, 2003; Iwamasa& Yamada, 2001; Roysircar, 2003). Drawing from the alternation model, LaFromboise et al. (1993) proposed a model of bicultural competence that emphasizes the reciprocal relationship between the person and the environment, or in this case, two environments (the culture of origin and the second culture). They suggested that competence in each of these cultures can be observed in the individual's (a) knowledge of cultural beliefs and values, (b) positive attitudes toward both majority and minority groups, (c) bicultural efficacy, (d) communica-
tion ability, (e) role repertoire, and (f) sense of groundedness in a social support system. This model may be helpful in one's exploration and choice of supports. For example, consider the situation of a middle-aged, urban American Indian woman. If the woman grew up in an American Indian family and cultural context, identifies strongly with her specific Native culture and functions well in the dominant cultural setting in which she works and lives, and currently is well grounded in a social support system that includes Native and non-Native people, the range and types of environmental supports that would be appropriate for her would be quite different from those of another middle-aged, urban American Indian woman who grew up in an adopted European American family with little connection to her cultural heritage. Whereas the first woman might be open to traditional rituals, supports, or healing practices in addition to some dominant cultural approaches, the second woman could interpret the suggestion of traditional rituals, supports, or healing practices as presumptive and thus racist. Cognitive Problems This brings us to the second category of problems, namely, those that can be thought of as internal to the client. These include overwhelming emotions, disturbing thoughts, frightening physical sensations, and maladaptive behavior. CBT refers to these problems as cognitive because the disturbance is seen as emanating from dysfunctional cognitions and cognitive processes. As noted earlier, CBT proposes that we can increase our control over disturbing physiological sensations, overwhelming emotions, and selfdefeating behaviors if we recognize our unhelpful cognitions and change them to more helpful, realistic, and positive ones. Attention to cultural influences within this second category of problems is important for several reasons. Culture plays a role in the creation, shaping, and maintenance of cognitions and cognitive processes (Dowd, 2003). Cultural influences can be seen in one's definitions of rationality and in one's view of what constitutes adaptive and maladaptive behavior. Cultural influences are interwoven with beliefs regarding acceptable coping behaviors and forms of emotional expression, and with religious and social values that affect clients' perceived choices. Because minority cultural influences are often framed as negative by the dominant culture, therapists will want to give deliberate attention to the positive aspects of cultural influences on internal processes. These can be conceptualized as personal strengths and include pride in one's culture and identity; a religious faith or spirituality; musical and artistic abilities; bilingual and multilingual skills; a sense of humor; culturally related knowledge and practical living skills regarding fishing, hunting, farming, cooking, and the use of medicinal plants; culture-specific beliefs that help one cope with
prejudice and discrimination; and commitment to helping one's group, for example, through social action. Here again, the client's connection to and competence in his or her culture of origin and the dominant culture are important. For example, consider the situation of a young Vietnamese man in his early 20s who lives in the United States with his parents and younger siblings and who presents with anxiety related to family and work conflicts. From a dominant cultural perspective, the therapist might conceptualize the client's problem as one of individuation and encourage him to question the authority of his parents and find his own place to live. Such an approach could involve challenging culturally based beliefs regarding respect for elders, responsibility to others, and interdependence of family members. If the client and his family are open to alternative cultural perspectives, considering these different views could be helpful. However, if they are not, such an approach would probably diminish the therapist's credibility and lead the young man to terminate therapy. More helpful approaches might involve teaching the client (and possibly the family) skills for problem solving, conflict resolution, and frustration tolerance that do not involve challenging core cultural beliefs. Addressing the Complexity of Problems Of course, environmental and cognitive aspects of problems often overlap. An ever-present danger with CBT lies in the inaccurate conceptualization of a client's problem (i.e., distress) as due to dysfunctional cognitions when it is a consequence of unacceptable environmental conditions (e.g., an abusive relationship, a racist workplace, physical obstacles to a person who has a disability). As therapists, we do not want to be in the position of encouraging a client to adapt to an environment that is dangerous or harmful. Attempts to change a client's thinking about such conditions without trying to change the conditions may give the message that the conditions are acceptable and that the client is to blame for them. Returning to the example of Julia, let's say that her coworkers and supervisor resent her promotion and that their feelings emanate from racial prejudice. In response to this environmentally based problem, the therapist would want to explore with Julia the possibility of taking action aimed at changing her work environment (e.g., talking to someone above her supervisor, filing a complaint, looking for a new job, consulting an attorney). However, if Julia's anxiety is so great that it prevents her from engaging in this type of problem solving, it may be necessary to take a more internal (cognitive) focus to managing the anxiety. This internal focus would involve helping Julia to change her self-defeating thoughts to more helpful ones that decrease her anxiety. Such cognitive restructuring might be conducted first or in combination with the problem solving aimed at changing Julia's environment.
Building on the existing literature in the domains of CBT and multicultural therapy, this book provides clinicians and counselors with practitioner-oriented suggestions, guidelines, and examples illustrating the use of CBT with people of diverse cultural identities. The book is intended forpsychologists, counselors, family therapists, social workers, and psychiatrists who are interested in using cognitive-behavioral approaches to assessment, therapy, and supervision with clients and students of diverse identities. It should appeal to those who already hold multicultural expertise and want to learn specific skills and interventions, as well as to cognitive-behavior therapists who wish to expand their approaches to more diverse populations. An underlying premise of the book is that culture influences us all, and the consideration of culture is an essential component of assessment and therapy with everyone. By focusing on the application of CBT with people of minority identities, we hope to call attention to the ways in which cultural considerations can enhance and facilitate CBT with people of minority, dominant, bicultural, and multicultural identities.
OVERVIEW OF THE BOOK The book begins with chapters 1 through 7 focusing on the use of CBT with specific ethnic cultures, including people of Native, Latino, Asian, and African American heritage, along with chapters on people of Arab and Orthodox Jewish heritage. Chapters 8 through 10 address the use of CBT with people of nonethnic minority groups: older adults, people with disabilities, and sexual minorities. In keeping with the conceptualization of identity as complex and multidimensional, these chapters do not assume a European American norm but rather include people of color who are older, have a disability, or are gay, lesbian, or bisexual. Whereas nonethnic minority groups are not always conceptualized as minority cultures, we believe that several aspects of these groups justify this conceptualization. All of the groups meet the broader definition of culture used in the multicultural counseling literature (Fukuyama, 1990; Pope, 1995). These groups share some experiences related to their identities and, in the case of sexual minorities and people with disabilities, a history of advocating for equal rights. Sexual minorities and people with disabilities each also have their own within-group terminology. Just as members of ethnic minority cultures are often the targets of prejudice and discrimination, so too are older adults, sexual minorities, and people with disabilities. And, on the positive side, the minority status that goes along with these identities has brought many members of these groups unique forms of knowledge, awareness, emotional and tangible support, and a sense of community (Newman & Newman, 1999). In chapters 1 through 10, each chapter offers an introductory overview of the respective cultural group, including sociodemographics and informa-
tion regarding within-group diversity. Chapter authors discuss the advantages of using CBT with each group, potential limitations, and suggested adaptations. Case examples illustrate the practical application of these adaptations. Chapters 11 and 12 address cultural considerations in cognitivebehavioral assessment, supervision, and training. One final note: Although we have done our best to include a diverse range of cultural influences and minority groups, there is still a long way to go. We recognize the need for more empirically based research involving minority cultures. In the meantime, we hope that the clinically based suggestions and modifications provided in this book will contribute to the search for and consideration of evidence-based practices. We look forward to future research involving an even greater number of cultural groups from a variety of countries.
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1 COGNITIVE-BEHAVIORAL THERAPY WITH AMERICAN INDIANS JUSTIN DOUGLASMCDONALD AND JOHN GONZALEZ The degree to which European American and American Indian perspectives differ regarding the topic of mental health could keep an army of cross-cultural psychologists working for decades. Unfortunately, no such army exists, and most of the cross-culturally competent "warriors" have concerned themselves with the larger ethnic minority groups, understandably so. The reasons for this disparity are legion and more fully described elsewhere (see McDonald & Chaney, 2003). The point remains that although much has been anecdotally discussed, very little has been empirically clarified. Nonetheless, as increasing numbers of American Indians receive doctorates in psychology (Benson, 2003), it logically follows that a new generation of culturally competent psychologists will fuel an interest in empirical clarity, and we should build and move in this direction. In this chapter, we have compiled and synthesized what information is available from the clinical literature with information from traditional American Indian Oral History and contemporary practice. We provide the reader with a brief history of American Indian demographic and cultural issues relevant to psychology in general and cognitive-behavioral therapy (CBT) in particular, followed by a case example that integrates consideration of these issues with the clinical application of CBT. 23

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