Transcript Document

Ten Steps to Culturally Competent
Evidence-Based Practice
Pamela A. Hays, Ph.D.
www.drpamelahays.com
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Agenda
8-8:30am
The Evidence-Based Practice of CBT: An Overview
Cross-Cultural Strengths & Limitations of CBT
8:30-9:50am
A New Framework For ADDRESSING Diversity
Break
10-11:50am
10 Strategies for Culturally Competent CBT
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Evidence-Based Practice in Psychology:
Integration of the best available research
with clinical expertise in the context of
patient characteristics, culture, and
preferences.
– APA Presidential Task Force on EBPP, 2006
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Historical/Cultural Development
Psychoanalysis
Behaviorism
Family
systems
Humanistic/Existential/
Feminist
CBT
Multicultural
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Behavioral Principles
1.
Emphasis on here & now.
2.
Person X Environment = Behavior
3.
All behavior is learned.
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Behavioral Principles…
4.
Adapt methods to each person’s
situation, needs, & strengths.
5.
Set clearly defined achievable goals.
6.
Ongoing assessment.
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5 Components of CBT
•
Environment/Situation
•
Emotions
•
Sensations
•
Behaviors
•
Cognitions
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Environment
Emotions/
Sensations
Thoughts/image
Behaviors
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CBT: Problem Conceptualization
A. Environmental/External
B. Cognitive/Internal
--overwhelming emotions
--disturbing physical sensations
--self-defeating behaviors
--unhelpful thoughts/images
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Problem Type
Intervention
Envir./External
Problem-solving
Environmental changes
Support groups
Behavioral skill building
Assertiveness training
Relaxation training
Modeling, reinforcement
Competing behaviors
Cog./Internal
Cognitive restructuring
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Cognitive Restructuring (def.)
--involves changing unhelpful thoughts
and images to more helpful ones, to
manage overwhelming emotions &
physical sensations, and change selfdefeating behaviors.
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Strengths of CBT across Cultures
1.
Emphasizes the uniqueness of each individual.
2.
Empowers clients via educational approach.
3.
Focuses on conscious processes & specific
behaviors.
4.
Integrates assessment throughout therapy.
5.
Emphasizes strengths & supports.
6.
Works across the lifespan (children, adults, elders).
7.
Considers cognitive, emotional, physical, behavioral
& environmental components of a problem.
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Limitations of CBT across Cultures
1.
Often assumed to be value-neutral.
2.
Emphasis on cognition, “rational” thinking, & confrontation.
3.
Focus on the present may result in neglect of generational &
historical influences.
4.
Emphasis on personal change may contribute to neglect of
oppressive environmental conditions.
5.
Heavy reliance on verbal abilities.
6.
Research is still predominantly ethnocentric.
7.
CBT jargon.
8.
Neglects the spiritual component.
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The ADDRESSING Framework
Cultural Influences
Minority Groups
Age/generational
Children, adolescents, elders
Developmental disabilities
Disabilities acquired
People with developmental disabilities
People with disabilities acquired later in life
Religion & Spirituality
Religious minority cultures
Ethnic & racial identity
Ethnic & racial minority cultures
Socioeconomic status
People of lower status by educ, income,
occup, rural habitat
Sexual orientation
Gay, lesbian, & bisexual people
Indigenous heritage
Indigenous/Aboriginal/Native people
National origin
Refugees, immigrants, international students
Gender
Women, transgender people
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Two Categories of Work
1.
Personal
2.
Interpersonal
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Essential Knowledge
1. Bias is best thought of as a tendency to
think, act, or feel in a particular way.
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Understanding Bias
Generalizations Biases
&
Biases
 Worldview
Categorizations Biases
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Essential Knowledge…
2. We’re all biased but we don’t all belong to
dominant cultural groups.
3. Bias + Power = Systems of privilege (‘isms).
4. Nonprivileged members are socialized to be
aware of the lines separating those who
have privilege from those who do not.
5. Privileged members are socialized to ignore
these lines and differences.
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The ADDRESSING Framework
Cultural Influences
Age/generational influences
Developmental disabilities
Disabilities acquired later In life
Religion & Spirituality
Ethnic & racial identity
Socioeconomic status
Sexual orientation
Indigenous heritage
National origin
Gender
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Culturally Responsive CBT
1. Assess Needs w/emphasis on Respectful
Behavior.
a. Explain what you do w/o jargon.
b. Slow down questioning process.
c. Use ADDRESSING to develop hypotheses.
d. Avoid questions that elicit negatives re: family or
culture.
e. Assess whether person wants change/what kind.
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CR-CBT…
2.
Use ADDRESSING framework to
generate Strengths & Supports
List.
a. What do you consider your strengths &
supports?
b. What would your mom/kids/friend say?
c. Do you have a connection to any religion or
spiritual practice?
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Culturally Related Personal Strengths

pride in one’s culture

religious faith or spirituality

artistic and musical abilities

bilingual and multilingual skills

group-specific social skills

sense of humor

culturally-related knowledge & practical skills (fishing, hunting,
farming, medicinal plants)

culture-specific beliefs that help one cope with others’ prejudice &
discrimination

respectful attitude towards the natural environment

commitment to helping one’s own group

wisdom from experience
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Interpersonal Cultural Supports

extended families including non-blood-related

cultural or group-specific networks

religious communities

traditional celebrations and rituals

recreational, playful activities

story-telling activities that make meaning and pass on
history of the group

involvement in political/social action group

a child who excels in school
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Environmental Cultural Supports
•
altar in home to honor deceased family members
•
space for prayer and meditation
•
culture-specific art and music
•
culturally preferred foods for cooking & eating
•
animals to care for
•
gardening area
•
access to outdoors for subsistence or recreational
fishing, hunting, farming, observing night sky
•
communities that facilitate social interaction by location
or design
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3. Consider Cultural Influences on
the 5 Components of CBT:

Environment

Emotions

Sensations

Behaviors

Cognitions
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Environment + Cultural considerations
•
Recognize cultural influences in the
environment
•
Acknowledge oppressive aspects
of the situation
•
Validate client’s personal
experience of oppression
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Emotions + Cultural Considerations
•
Consider differences in emotional
expressiveness
•
Consider differences in reporting emotion
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Sensations + Cultural Considerations
•
Consider somatic expressions of
distress
•
Consult with physician regarding
somatic complaints.
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Behavior + Cultural Considerations
•
Recognize that culture shapes all
behaviors.
•
Be familiar with culture-bound
syndromes.
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Cognition + Cultural Considerations
•
Consider cultural values that affect
perceived options.
•
Consider cultural norms (beliefs)
including different definitions of
rationality, adaptive/maladaptive
behavior, & health.
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CR-CBT…
4. Clarify what part of the problem is
primarily external & what part is
primarily internal.
a. Validate experiences of
oppression.
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CR-CBT…
5. For External, consider Culture w/:
•
•
•
•
•
•
•
•
Problem-solving
Environmental changes
Support groups
Behavioral skill building
Assertiveness training
Relaxation training
Modeling, reinforcement
Competing behaviors
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CR-CBT…
6. For Internal problem, use Cognitive
Restructuring w/ emphasis on
collaboratively exploring the
helpfulness of a thought, belief, or
image (rather than rationality or
validity).
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CR-CBT…
7. Be cautious about the Downward
Arrow Technique
(e.g. “So what if that were true?” “What is the
worst that could happen?”)
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CR-CBT…
8. Do not challenge a core
cultural belief unless client is
open to this.
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CR-CBT…
9. Use Culturally Related Strengths
& Supports List to generate more
helpful thoughts & images.
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CR-CBT…
10. Develop culturally congruent
homework that emphasizes
client direction.
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Culturally Responsive CBT
1.
2.
3.
4.
5.
Assess needs w/emphasis
on respectful behaviors.
Use ADDRESSING to
generate Strengths and
Supports List.
Define the 5 Components w/
Cultural considerations.
Clarify External & Internal
parts of problem.
For External part, use
Environmental Intervention
w/Cultural considerations.
6.
7.
8.
9.
10.
For Internal part, use
Cognitive Restructuring that
collaboratively considers
helpfulness of thoughts.
Be cautious w/Downward
Arrow Technique.
Don’t challenge core cultural
beliefs.
Use Culturally Related
Strengths & Supports List to
generate helpful thoughts.
Culturally congruent
Homework w/client direction.
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A major obstacle to Culturally Competent
Evidence-Based Practice is
DEFENSIVENESS.
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Think of a situation with a person in which you
began feeling defensive:
1.
What led to your defensive feelings?
2.
What were your physical sensations & emotions?
3.
What were you thinking?
4.
What did you do? What did you say?
5.
What did the other person do & say?
6.
Did you spiral down or were you able to stop the
spiral?
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Preventing Defensive Behaviors
1.
Become aware of physical sensations related
to feelings of defensiveness.
2.
In the moment, take a deep breath, exhale
slowly, and focus on your breath.
3.
Refrain from defensive behaviors .
4.
Ask yourself: What does this person want?
5.
Try focusing on the content (vs. voice tone,
volume, or nonverbal behaviors ).
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Preventing Defensive Behaviors…
6. Question the need for this person's views to
match your own.
7. Reframe irritations & annoyances as
opportunities for growth.
8. Recognize your need for additional information
and/or experience.
9. If appropriate, discuss the limitations of your
knowledge and experience with the person.
10. If appropriate & possible, use humor.
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Resolving Value Conflicts
1.
Look for the shared value.
2.
Recognize differences in value
priorities.
3.
Reframe differences using positive
language.
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Reframing Value Differences
Assumption
Reframe
Egalitarian vs. Authoritarian
Respect
Independent vs. Dependent
Interdependent
Open vs. Closed
Self-Control, Mature
Change vs. Resistant
Patient
Hard work vs. Lazy
Enjoys life
Honest vs. Dishonest
Harmony
Active vs. Resigned
Accepting
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