Ten Steps to Culturally Competent Evidence-Based Practice

1. Ten Steps to Culturally CompetentEvidence-Based Practice Pamela A. Hays, Ph.D. www.drpamelahays.com

2. 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

3. 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

4. Historical/Cultural Development Psychoanalysis Behaviorism Family systems Humanistic/Existential/ Feminist CBT Multicultural

5. Behavioral Principles • Emphasis on here & now. • Person X Environment = Behavior • All behavior is learned.

6. Behavioral Principles… • Adapt methods to each person’s situation, needs, & strengths. • Set clearly defined achievable goals. • Ongoing assessment.

7. 5 Components of CBT • Environment/Situation • Emotions • Sensations • Behaviors • Cognitions

8. Environment

9. CBT: Problem Conceptualization A. Environmental/External B. Cognitive/Internal --overwhelming emotions --disturbing physical sensations --self-defeating behaviors --unhelpful thoughts/images

10. Envir./External Cog./Internal Problem-solving Environmental changes Support groups Behavioral skill building Assertiveness training Relaxation training Modeling, reinforcement Competing behaviors Cognitive restructuring Problem Type Intervention

11. Cognitive Restructuring (def.) --involves changing unhelpful thoughts and images to more helpful ones, to manage overwhelming emotions & physical sensations, and change self-defeating behaviors.

12. Strengths of CBT across Cultures • Emphasizes the uniqueness of each individual. • Empowers clients via educational approach. • Focuses on conscious processes & specific behaviors. • Integrates assessment throughout therapy. • Emphasizes strengths & supports. • Works across the lifespan (children, adults, elders). • Considers cognitive, emotional, physical, behavioral & environmental components of a problem.

13. Limitations of CBT across Cultures • Often assumed to be value-neutral. • Emphasis on cognition, “rational” thinking, & confrontation. • Focus on the present may result in neglect of generational & historical influences. • Emphasis on personal change may contribute to neglect of oppressive environmental conditions. • Heavy reliance on verbal abilities. • Research is still predominantly ethnocentric. • CBT jargon. • Neglects the spiritual component.

14. The ADDRESSING Framework Cultural InfluencesMinority Groups Age/generational Children, adolescents, elders Developmental disabilities People with developmental disabilities Disabilities acquired 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

15. Two Categories of Work • Personal • Interpersonal

16. Essential Knowledge 1. Bias is best thought of as a tendency to think, act, or feel in a particular way.

17. Understanding Bias Generalizations Biases & Biases  Worldview Categorizations Biases

18. 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.

19. 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

20. 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.

21. CR-CBT… • 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?

22. 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

23. 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

24. 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

25. 3. Consider Cultural Influences on the 5 Components of CBT: • Environment • Emotions • Sensations • Behaviors • Cognitions

26. Environment + Cultural considerations • Recognize cultural influences in the environment • Acknowledge oppressive aspects of the situation • Validate client’s personal experience of oppression

27. Emotions + Cultural Considerations • Consider differences in emotional expressiveness • Consider differences in reporting emotion

28. Sensations + Cultural Considerations • Consider somatic expressions of distress • Consult with physician regarding somatic complaints.

29. Behavior + Cultural Considerations • Recognize that culture shapes all behaviors. • Be familiar with culture-bound syndromes.

30. Cognition + Cultural Considerations • Consider cultural values that affect perceived options. • Consider cultural norms (beliefs) including different definitions of rationality, adaptive/maladaptive behavior, & health.

31. CR-CBT… 4. Clarify what part of the problem is primarily external & what part is primarily internal. a. Validate experiences of oppression.

32. 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

33. 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).

34. 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?”)

35. CR-CBT… 8. Do not challenge a core cultural belief unless client is open to this.

36. CR-CBT… 9. Use Culturally Related Strengths & Supports List to generate more helpful thoughts & images.

37. CR-CBT… 10. Develop culturally congruent homework that emphasizes client direction.

38. 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. 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. Culturally Responsive CBT

39. A major obstacle to Culturally Competent Evidence-Based Practice is DEFENSIVENESS.

40. Think of a situation with a person in which you began feeling defensive: • What led to your defensive feelings? • What were your physical sensations & emotions? • What were you thinking? • What did you do? What did you say? • What did the other person do & say? • Did you spiral down or were you able to stop the spiral?

41. Preventing Defensive Behaviors • Become aware of physical sensations related to feelings of defensiveness. • In the moment, take a deep breath, exhale slowly, and focus on your breath. • Refrain from defensive behaviors . • Ask yourself: What does this person want? • Try focusing on the content (vs. voice tone, volume, or nonverbal behaviors ).

42. 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.

43. Resolving Value Conflicts • Look for the shared value. • Recognize differences in value priorities. • Reframe differences using positive language.

44. Assumption Egalitarian vs. Authoritarian Independent vs. Dependent Open vs. Closed Change vs. Resistant Hard work vs. Lazy Honest vs. Dishonest Active vs. Resigned Reframe Respect Interdependent Self-Control, Mature Patient Enjoys life Harmony Accepting Reframing Value Differences