Transcultural Cognitive Behaviour Therapy for Anxiety and Depression

A Practical Guide

Andrew Beck

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9781138890473
• eBook ISBN: 9781317479772
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Transcultural Cognitive Behaviour Therapy for Anxiety and Depression is a practical and accessible guide, drawing on current research in CBT and clinical practice. It aims to support therapists in taking a reflective and evidence based approach to genuinely improving access and outcomes for Black and Minority Ethnic service users. It highlights the skills that clinicians need to undertake Culturally Adapted and Culturally Sensitive CBT and provides practical ideas and case examples that will enable therapists to feel confident in adapting models of assessment and treatment across cultures.

The emphasis of this book is on practical clinical techniques and approaches but it is firmly grounded in the research literature on this topic. Therapists, supervisors and service leads will find useful ideas to support and enrich transcultural working and develop their confidence when applying evidence based interventions across cultures.

Transcultural Cognitive Behaviour Therapy for Anxiety and Depression will be of interest to Improving Access to Psychological Therapies (IAPT) trained cognitive behaviour therapists, clinical psychologists and cognitive behaviour therapists. The book will also appeal to those undertaking advanced or postgraduate studies in CBT.

Chapter 1

Introduction

Why we need to think and work transculturally

Transcultural approaches to health care are based on the idea that the values and beliefs of different cultural groups need to be understood in order to provide services which reflect the distinct ways that these groups conceptualise health problems, act in response to these and engage with treatment. This framework enables health workers to collaborate with service users in a way that takes their culture into account whilst also identifying factors which are common across communities and making use of evidence based approaches to health care developed for majority ethnic groups (Andrews and Boyle 2008).

Cultural and ethnic diversity in Europe and North America has increased at an unprecedented rate over the past 70 years, and with this has come the challenge of providing mental health services which reflect this diversity and which respond to the values and beliefs of newer or growing communities. Cognitive Behaviour Therapy (CBT) is the most widely available psychological therapy in the UK and many other countries. It is supported by a strong evidence base for its efficacy for a wide range of problems and is likely to be the first psychological therapy offered to most people using mental health services.

Cognitive Behaviour Therapy was developed in clinical settings in North America and Europe where the majority of therapists, researchers and service users were from a White European cultural background. The core beliefs about mental health and its treatment implied by this model have their origins in Western concepts of emotional well-being and illness. The majority of the clinical observations and initial research which led to the development of the disorder specific models which underpin CBT were done with white clinical populations, and almost all of the subsequent research into the efficacy of CBT has been done with white participants. This does not mean that CBT cannot be helpful for service users from Black and Minority Ethnic communities – this book looks at some very good examples of adapted CBT which have shown excellent clinical outcomes – but it does mean that therapists need to think carefully about the way that CBT might be used across cultures and in different contexts in order for it to be effective.

As CBT skills have become widely disseminated in mental health settings and the populations served by teams become more ethnically diverse, cognitive behaviour therapists often find themselves working with service users from cultural backgrounds which are different to their own. This means that therapists may have to adapt their ways of working to take into account the culture and context of these service users. There is very good evidence to support the idea that culture, language, ethnicity and religion have a considerable impact on the way that mental health problems manifest themselves (Gone and Kirmayer 2010), and that these factors will shape symptoms, how people experience their problems, their explanations for the problem and the way that they might seek help. Understanding these processes will help to ensure that BME service users benefit from the same clinical outcomes as white service users.

In response to the challenge of working across cultures and contexts there have been a number of research projects evaluating both Culturally Adapted CBT (CA-CBT) and Culturally Sensitive CBT (CS-CBT), and research into these two ways of working across cultures suggests that outcomes can be as good as those for white service users. The difference between CA-CBT and CS-CBT is summarised at the end of this chapter and considered in more detail in Chapter 5, which contrasts ways of using these two approaches in the treatment of post-traumatic stress disorder (PTSD).

Who this book is for

This book is written for practitioners working across the lifespan in mental health services and who use or would like to use CBT with BME service users. It assumes a broad working knowledge of CBT but is written with both the novice and the expert therapist in mind. The assumption of much of the book is that it is written for a white therapist working with a BME service user. This is not meant to suggest that there are no challenges for BME therapists who are working transculturally or with service users from within their own ethnic group. When indicated there are specific references to the research literature looking at therapy issues relating to perceived sameness or closeness of culture.

The book does not set out to provide a step-by-step guide for success in working across cultures. Instead it sets out some broad principles and approaches which have come from both the research literature and clinical experience. The chapters are illustrated with case examples, though care has been taken to change the details of cases to protect the confidentiality of patients. Practitioners are encouraged to keep a reflective learning log in order to facilitate use of these ideas and techniques and to use supervision as a forum for further reflective practice.

How this book might help therapists using CBT across cultures

In mental health services in much of the English-speaking world there has been a growing recognition that the needs of BME communities are often not well met. This is largely because the way that services are organised, mental health is conceptualised and therapies are delivered reflects a Western view of mental health that might not sit well with the way that mental health is understood in other cultures. There is a growing recognition that interventions need to take into account diverse values and beliefs and that services need to engage with the communities they serve in order to understand how to adapt the way that therapies are provided. Although the availability of CBT has increased considerably over recent years, the evidence base regarding how to adapt and apply this model to BME groups has not kept pace with these service developments, and where evidence does exist it has often not been disseminated into teams.

This book starts from the assumption that CBT can be an effective treatment for BME service users, but that in order for it to be effective practitioners need to adapt the way that they work. This includes how they might engage service users, how they formulate presenting problems in ways that take into account culture and context, how disorder specific models are used and how confident therapists are about discussing and thinking about culture in therapy and in supervision.

Adapting CBT across cultures can be a considerable challenge for therapists. They might feel unprepared to do this, as it is seldom covered in any depth on training courses. Therapists might not feel confident discussing culture and difference with service users, might not be confident that good therapy outcomes can be achieved and might struggle to provide CBT through interpreters.

This book is written as a resource for therapists in order for them to be more comfortable and confident when working across cultures and as a resource for supervisors, managers and service leads in order for them to think about how they might need to adapt their service to meet the needs of the patients they serve.

Most cognitive behavioural therapists work with service users from BME communities, but many therapists report that they are reluctant to bring up issues regarding ethnicity or culture in case they do so in a way that undermines the therapeutic relationship. This book sets out to give therapists the confidence to think about ethnicity and culture with service users and incorporate this information into formulations in a way that will improve engagement and clinical outcomes. It also provides a framework for looking at patterns of service use amongst ethnic minorities and to consider the way that these populations can be involved with participation and service design in a way that leads to services that are responsive to the particular needs of local populations.

It seems reasonable to assume that as clinicians develop a greater understanding of a client’s conceptualisation of ethnicity and its relationship to their mental health there will be improvements in the way that therapy is provided and better clinical outcomes for BME service users (Department of Health 2005). Research suggests that therapist awareness and sensitivity may be more important for service users who perceive a relationship between their ethnicity and their psycho-social well-being than for service users who see little relationship between their ethnicity and their use of mental health services (Pope-Davis et al. 2002), but it is only possible to know how someone understands these relationships through therapeutic discussion and exploration.

The rapid growth of CBT

It is almost 40 years since the foundations of CBT were established by Aaron T. Beck in his seminal book on the treatment of depression (Beck et al. 1979) and in that time CBT has become one of the most influential models to both describe and treat mental health problems, across the lifespan and in a wide variety of settings.

This expansion can be attributed to three factors. The first is the flexibility of the approach. CBT has been adapted for a wide range of presenting problems, contexts and situations. This flexibility has enabled it to be used across the lifespan from childhood mental health problems to difficulties in old age, in physical health care settings and with people with cognitive or neurodevelopmental difficulties. The second factor is that key concepts can be readily understood by mental health practitioners, service users and referrers. It is a model that is easy to explain to others and which has a great deal of face validity. The third factor is that there has been a clear commitment to establishing a credible evidence base for the efficacy of CBT from the start. This has meant the adoption of high standards of research methods, including randomised control trials (RCTs), which are seen as the gold standard for outcomes research in health care settings. This research has given CBT a reputation for demonstrable effectiveness that appeals to service users, therapists, referrers and commissioners of services.

Health economics are also likely to have driven the growth in CBT in recent years as this therapy is seen as a more cost effective form of treatment for depression and anxiety disorders than many other therapeutic approaches (Layard et al. 2006, Gyani et al. 2013). This means that scarce mental health resources can be used to help more people, but it is also assumed that individuals are more likely to return to being economically active as a result of successful therapy. From an economic point of view transcultural CBT is likely to use more resources than CBT which is unmodified. It may take more sessions and need more resources to engage individuals and families and to work with wider systems. Interpreter mediated CBT can often need longer sessions or more sessions to complete. Clinicians providing transcultural CBT are also likely to need additional support through appropriate training and supervision in order to successfully adapt the model across cultures and contexts, and this will also have additional resource implications.

Culturally Adapted CBT or Culturally Sensitive CBT?

This book considers two approaches to using CBT to meet the needs of BME service users: Culturally Adapted and Culturally Sensitive CBT. Both approaches have something to offer therapists, but it might be useful to distinguish between the two at this stage.

Culturally Adapted CBT

Culturally Adapted CBT (CA-CBT) can be best understood as

a middle ground between the two extreme positions of considering an original evidence based intervention as applicable to all cultural groups without the need for adaptation, and a culture-specific approach with emphasis on unique culturally grounded content and process.

(Chowdhary et al. 2014)

Taking this approach ensures that the basic active components of CBT are retained whilst incorporating elements of the distinct and culturally mediated aspects of the way that mental health problems are expressed and understood. This approach is based on an assumption that mental health problems are universal phenomena but that specific manifestations, in terms of thoughts, behaviour and family processes, might be specific to particular cultures (although Culturally Sensitive CBT is also based on this premise).

The steps for the cultural adaptation of therapies

A useful way of understanding the steps necessary in cultural adaptation for all psychological therapies has been developed by Bernal and Sáez-Sangriago (2006). This framework considers a number of possible domains within which adaptation can take place. These are summarised below:

1 The language in which therapy is conducted is considered a key element in adaptation, as language is often the means by which culture is expressed and transmitted. This dimension also includes the adaptation of communi-cation styles.

2 The degree to which the therapy considers the ethnic and cultural similarities and differences in the service user–therapist relationship. This might involve explicitly matching the ethnicity of therapist and service user or including reflective practice about the degree to which this impacts on therapy. It might also include a recognition that some cultural groups might prefer a more collaborative stance for this relationship whilst others might prefer a more didactic therapist.

3 Adaptation accounts for the use of metaphors and incorporates the particular idioms or sayings of a cultural or ethnic group into the therapeutic language and approach.

4 The content of the therapy and how knowledge about cultural practices, values and behaviours are incorporated into the therapy approach.

5 Therapy goals are seen as a key area, and the authors emphasise the need for therapists to work collaboratively with service users to establish goals that reflect the values and aspirations of the service user.

6 Therapy methods; this refers to the way that therapy techniques reflect or are compatible with the practices of the community for which the therapy is being adapted.

7 The incorporation of context; this refers to an appreciation of the setting within which the BME service users find themselves, including their economic and educational opportunities, experience of racism or other forms of discrimination and, in some cases, their migration history and degree of acculturation if the adaptation is occurring in a Western context.

Adaptations might not incorporate all of these elements, and may not need to do so in order to have successful therapy outcomes, but this list of components does provide therapists with a framework for evaluating particular approaches in order to see to what extent and how a particular therapy has been culturally adapted.

Culturally Sensitive CBT

In contrast, Culturally Sensitive CBT (CS-CBT) tends to look much more like CBT as provided to white majority service users, but with adaptations made on a case-by-case basis by therapists, service users and sometimes interpreters. Therapists using this approach will draw on a set of core principles which include an acknowledgement of the need to collaboratively discuss and understand the cultural background of the service user; to think about whether disorder specific models are the best fit to describe their difficulties; to appreciate that metaphors and ideas used in one culture may not translate into another; and to recognise that it is important to think about the lived experience of the service user as a member of a BME community and what particular strengths and challenges this might bring. Chapter 5 provides a summary of the culturally sensitive approach developed by d’Ardenne et al. (2005), and Chapters 2 and 3 provide a basis for therapists to begin to discuss and think about culture and ethnicity in a way that supports culturally sensitive working.

Therapists working in an area where there is one major BME community might find developing knowledge and skills regarding a particular CA-CBT useful. Where therapists work with service users from a broad range of ethnic backgrounds, a culturally sensitive approach might be a more useful position to take, as CA-CBT is usually only adapted for a specific ethnic group and for a specific disorder. On the whole, a culturally sensitive position might underpin the majority of transcultural work and provide therapists with the flexibility to work with someone from any community with any presenting problem.

Cross-cultural adaptations of therapies and interventions are typically adapted from a model developed for white Europeans to one suitable for BME populations living within Western countries or to majority populations in other countries. One possible exception to this is mindfulness based cognitive therapies, whose origi...

Table of contents

• Cover Page
• Transcultural Cognitive Behaviour Therapy for Anxiety and Depression
• Praise
• Title
• Copyright
• Contents
• Acknowledgments
• Preface
• 1 Introduction: Why we Need to Think and Work Transculturally
• 2 How to Discuss Ethnicity and Culture with Service Users and why it can Improve Outcomes
• 3 Using Family Systems, Migration Histories and Acculturation in Assessment and Formulation
• 4 Disorder Specific Models in Transcultural CBT
• 5 Post-Traumatic Stress Disorder: Culturally Adapted or Culturally Sensitive CBT?
• 6 Integrating Religious or Spiritual Beliefs and Practices with CBT
• 7 Interpreter Mediated CBT: The Limits of Language Might not be the Limits of Cognition
• 8 Why Service-Wide Change is Needed to Support Transcultural CBT
• 9 How Confident can Clinicians be about Using Outcome Measures Across Cultures?
• 10 How to Use Supervision to Enhance and Support Transcultural CBT
• index