by Joye C. Anestis
One of the most common criticisms of the empirically-supported treatment (EST) movement is the belief that structured treatments (which involve treatment manuals) are rigid and do not take into account individual characteristics. In actuality, most ESTs provide a great deal of flexibility when it comes to applying the treatment to specific clients. A treatment manual provides the framework for the therapy, giving general directions on the tasks to be completed in a certain order, but the therapist does not simply read from the manual to the client like a robot (if that was the case, I'm sure no one would return to treatment). Individual characteristics of both client and therapist dictate many of the specifics of the treatment. One area in which this point may be crucial is when addressing cultural considerations of the client. It is often (but not always) necessary to consider specific aspects of culture (e.g., race, ethnicity, gender, sexual orientation, religion, age, disability) when treating a mental illness.
To this end, Pamela Hays published a succinct article on multicultural applications of cognitive-behavior therapy (CBT), a therapy which is considered to be an EST for a wide variety of mental illnesses. It is important to note that in conducting research on psychotherapies, issues of culture have often been neglected. Almost all therapies that exist today were created from a male, Euro-American, university-educated perspective. That doesn't mean that these therapies aren't effective for multicultural clients, just that more research is needed to confirm that our therapies are indeed multicultural. For example, there is nothing inherent in CBT that would make it be inappropriate for use with diverse clients. In fact, Hays notes specific ways in which CBT may be particularly useful for multicultural clients:
- CBT emphasizes the uniqueness of the individual: At its core, CBT argues that the treatment should be adapted to meet the needs of the individual.
- CBT focuses on client empowerment: The inherent belief that clients are in control and, therefore, capable of bringing about change themselves helps create a collaborative relationship which appreciates individual and cultural differences.
- CBT focuses on conscious processes and specific behaviors (instead of unconscious processes and abstract ideas): Hays notes that this may be especially important when therapy is conducted in a client's second (or third, etc.) language or with an interpreter. Research indicates that fluency in a 2nd language is negatively affected by emotional distress. A therapy that emphasizes theoretical and abstract ideas may result in a greater potential for misunderstanding between the therapist and a distressed client.
- CBT integrates assessment throughout the course of therapy: This cognitive-behavioral assessment maps progress from the client's perspective. In fact, assessment measures could easily be added to the battery that address concepts important to the client (e.g., the family's views of the client's progress). Additionally, this emphasis on continuing assessment demonstrates therapist commitment and respect for the client's opinion, which is important for all clients, but perhaps more so for the client and therapist whose backgrounds differ.
Hays does note, however, that CBT possesses some limitations that must be considered with diverse clients. CBT does value characteristics such as assertiveness, personal independence, verbal ability, and change, concepts that are prioritized in the United States, but not in many other cultures. CBT certainly has the potential to assist clients with other values, but therapists must work hard to battle their own subtle biases that support these concepts. Additionally, CBT generally de-emphasizes the importance of the client's history (i.e., it is very present-focused). Therapists should be careful not to disregard potential differences in a client's upbringing and experiences in the world, if they are relevant to the problems at hand (e.g., these developmental concepts could be incorporated into the cognitive schema). Finally, CBT emphasizes rational thinking and the scientific method, styles of thinking that are decidedly Euro-American and masculine. Certainly, these styles of thinking and interaction could be modified to fit the client's perspective.
Hays concludes the article with examples from the literature of adapting CBT to specific aspects of culture. These adaptations do not change the basic work and techniques of CBT, instead they incorporate and appreciate diverse beliefs into the standard CBT protocol. For example, Johnson and Ridley (1992) wrote of adapting rational-emotive therapy for Christian clients in three ways. Clients were encouraged to challenge irrational beliefs by using the Bible to define the "ultimate truth." Prayer and Christian content was emphasized throughout the therapy, and each session ended with a prayer focusing on the session content and asking Christ's assistance in overcoming irrational thoughts. As this example points out, the primary work of the therapy is unchanged but recognizing important aspects of the client's life can, in some cases, make treatment more palatable and appealing to the client. I would imagine in this case treatment adherence and attendance would rise as well.
What are your thoughts on cultural adaptations of CBT? Do you have other examples of cultural adaptations which are helpful?
For more information on being a culturally competent therapist, check out these resources in our bookstore:
- Mental Health Care for People of Diverse Backgrounds
- Counseling the Culturally Diverse: Theory and Practice
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
Subscribe in a reader
