Culturally Responsive CBT for Latino Youth and Families

1. Culturally Responsive CBT for Latino Youth and Families Rebecca Ford-Paz, PhD Children’s Memorial Hospital Northwestern Feinberg School of Medicine May 21, 2010

2. Overview • Importance of addressing cultural issues • Health Disparities • Debate about cultural adaptation of evidence-based treatment • Pros and cons of using CBT with Latino youth • Operationalize clinical recommendations for implementing culturally responsive CBT

3. Why is culture important? • Racial ethnic minorities will comprise more than half of US children by 2023 • Latino population is projected to jump to 1/3 of the US population by 2050 • In 2006, 85% of psychologists were of European American decent

4. Health Disparities • Surgeon General’s report on mental health disparities for racial and ethnic minorities (2001) • Less access to mental health services • Less likely to receive mental health services when needed • Likely to receive poorer quality of mental health care • Underrepresented in mental health research • Even when treated, ethnic minorities • Terminate prematurely • Improve more slowly • Evidence poorer outcomes • Ethnic minorities experience disproportionately more psychosocial stressors than do non-Latino White Americans

5. Health Disparities • A disproportionate number of children of color are referred for mental health services • Children of color still under-represented in RCTs of evidence-based treatments (EBTs)

6. Controversy about Culturally Adapted Treatments • Proponents highlight differences among cultural groups and suggest tailoring interventions to specific groups • Cultural adaptations can substantially improve engagement, perceived acceptability of the treatment, recruitment in clinical trials, and retention of minorities in treatment • Suggested adaptations • Creation of entirely new treatments for different ethnocultural groups • Modifying existing evidence-based treatments (EBTs) to address cultural factors

7. Controversy about Culturally Adapted Treatments • Opponents express concern about promotion of further stereotyping and the neglect of plural cultural identities • Rigorous testing of EBTs with ethnic minorities is limited – so the first priority should focus on dissemination and treatment outcome research • Cultural adaptation would be premature and possibly unwarranted • Cultural adaptation might compromise the fidelity of the intervention and its effectiveness • Concern that active core elements would be diluted or delivered later • Impossible to adapt every EBT for every cultural group

8. What do we know? • So far, research DOES NOT support the superiority of culturally adapted treatment over standard EBT, beyond improving treatment engagement (Huey & Polo, 2008) • BUT this research is limited, has a number of methodological flaws, and a lacks RCTs with ethnic minorities • Adaptation ideas • EBT should be maintained in its original form with all groups, only tailoring the intervention when barriers or opportunities arise • Selected adaptation guided by empirical evidence – inequitable treatment response to EBT

9. So, what do we (clinicians) do? • Feasible and empirically informed strategies do exist to infuse culture into: • Assessment • Case formulation • Treatment planning • Engagement • Implementation of CBT with diverse youth

10. PRO Basic tenets of CBT should be universal: Behavior is learned and can be unlearned. Thoughts, feelings, and behaviors are interrelated. Social learning and operant conditioning are universal processes CONs Belief in the universality of CBT – that it is culture-free, value neutral, or color blind came about from research that has focused on middle class, heterosexual White people Emphasis on rational thinking may overlook the importance of spirituality, context and relationships Some CBT skills may directly conflict with collectivist cultural values Pros and Cons of Using CBT with Diverse Populations

11. PROs CBT is clear, straightforward, and understandable Fits with client expectations Educational approach demystifies therapy and roles Focus on specific behaviors, thoughts, and emotions advantageous for clients whose first language is not English CON Reliance on written assignments or bibliotherapy may not be appropriate for those whose native language is not English or for those with little formal education Pros & Cons

12. PROs Short-term, problem-focused, present-oriented Directive, goal-oriented therapy consistent with needs of families in crisis, with few resources CONs Focusing exclusively on problem behaviors may neglect the importance of therapeutic alliance Focus on present and future may discount client’s history and neglect important cultural experiences Pros & Cons

13. PRO Action-oriented approach and focus on empowerment a strength for groups exposed to oppression CONs No specific CBT strategies address the impact of racism/oppression on minority clients Too much focus on changing individual variables to effect change and to adapt to the current environment Pros & Cons

14. Simply Pros • CBT does not view behavior as good or bad, but rather functional or not given the context • CBT emphasizes assessment throughout treatment and tailoring the intervention to the individual and his/her unique context • Collaborative nature and determination of mutually defined goals • Consideration and respect of clients’ perspectives on progress, financial and time constraints

15. Simply Pros • Compared to other therapeutic modalities, CBT found to have the strongest record of success with minority youth • CBT possibly and probably (for some disorders) efficacious for minority youth • CBT has demonstrated effectiveness for a variety of problems in ethnic minority adults

16. Over-Arching Themes Relevant to Culturally Responsive CBT • Intersection of development and culture • Individualism vs. Collectivism

17. Over-Arching Themes Relevant to Culturally Responsive CBT • Oppression, “-isms” and ethnic identity • Acculturation and immigration issues

18. Over-Arching Themes Relevant to Culturally Responsive CBT • Religion and spirituality • Distinctive symptom presentation • Contextual factors

19. Suggestions for Beginning CBT with Latino Children and Adolescents

20. Therapist Self-Assessment • Self-eval of one’s own • Cultural values • Notions of acceptable behavior that may be culturally-laden • Personal experience with social oppression vs. privilege • Knowledge deficits • Comfort addressing and discussing issues of diversity and discrimination • Personal biases • Know your own cultural identity and the significance of belonging to that cultural group

21. Assessment • Basic cultural competence: balance between educating oneself about the sociocultural groups to which your clients belong and recognizing that their experiences are unique and are not necessarily dictated by their group membership. (Pantalone et al., 2010)

22. Tools to Guide Assessment • Culturally Informed Functional Assessment (Tanaka-Matsumi et al., 1996) • ADDRESSING (Hays, 2008) • Age and generation • Developmental and acquired Disabilities • Religion/spiritual orientation • Ethnicity • Social status • Sexual orientation • Indigenous heritage • National origin • Gender

23. Treatment Engagement • Engagement may be challenging due to stigma and the history of exploitation, abuse, and disparities in mental health care • Address cultural differences between clinician and client • Home visits and phone outreach • Allow more time for rapport-building in initial stages of treatment and engage the client and family in “small talk”

24. Treatment Engagement • Matching client-clinician demographics, language, and mode of expression • Self-disclosure

25. Treatment Engagement • Psychoeducation • Clarification of roles • Explanation of CBT therapy model • Pretherapy orientation videos • Problem-solve barriers to treatment • Include important people such as curanderos, extended family, clergy, and comadres

26. Implementing CBT with Latino Youth and Families

27. Implementing CBT with Latino Youth: Family-Focused Intervention • May enhance effectiveness of CBT interventions with Latino youth • To be congruent with familismo, parent goals need to be considered in assessment and treatment phases • Discuss familial acculturation process • Clinicians should be careful not to impose their own values when there is a clash between the individual’s and family’s obligations

28. Implementing CBT withLatino Youth: Cognitive Restructuring • Dichos: • “La gota de agua labra la piedra.” • “Todo es según el color del cristal con que se mira.” • Simplify the ABCDE method • Activating Event • Beliefs • Consequences • Disputation of irrational beliefs • Effects of disputation • “Yes, but … Technique”

29. Implementing CBT withLatino Youth: Cognitive Restructuring • Cognitive restructuring is not to be used to adjust the child’s mindset to fit an unjust environment • Culturally responsive CBT recognizes the injustices facing Latino youth. • Distorted cognitions are not always the source of the problem • Even when there is no distorted cognition, however, cognitive restructuring can be used to assign responsibility and positively affect mood.

30. Implementing CBT withLatino Youth: Cognitive Restructuring • Cognitive restructuring is particularly useful to challenge cognitions stemming from internalized oppression • Use of scriptures and religious anecdotes to challenge maladaptive cognitions of spiritual/religious clients

31. Implementing CBT withLatino Youth: Behavioral Activation • “Para nadar, hay que tirarse al agua.” To swim you’ve got to get in the water. • “Camarón que se duerme, se lo lleva la corriente.” The shrimp that falls asleep gets taken by the tide. • “El que busca, encuentra.” He who seeks shall find. • “Ojos que no ven, corazon que no siente.” Eyes that don’t see, heart that does not feel. • “A quien madruga, Dios ayuda.” God helps early risers. • “Poner de su parte.” Do one’s part to overcome negative mood.

32. Implementing CBT withLatino Youth: Behavioral Activation • Attend to contextual factors such as income, safety of neighborhoods, gender roles, and cultural norms when planning behavioral activation interventions. • Create activity schedules that the youth can do with and without the family • For traditional Latinas and parents, frame behavioral activation as “By taking care of yourself, you will be better able to care for/participate in the family.” • Use physical exercise, distraction, and relaxation as a sensible intervention for somatic symptom presentation • Useful complement to cognitive restructuring to buffer youth from oppressive influences by connecting them to culturally specific institutions

33. Implementing CBT withLatino Youth: Problem-Solving • Problem-solving focuses on effecting change on the environment • Help youth draw upon family and community resources to address unjust treatment • Increases self-efficacy • Effect change at higher systemic level

34. Implementing CBT withLatino Youth: Exposure Therapy • Demonstrate sensitivity to cultural and religious taboos/prohibitions • Explain in detail the rationale for exposures and separate the disorder from the child’s identity

35. Implementing CBT withLatino Youth:Assertiveness Training • Frame assertiveness training as a way to help children develop bicultural competency. • Help the youth recognize when assertive communication may be inappropriate depending on the context • Be mindful of culture-based protocols of communication (respeto, simpatia) • Prefacing statements with: • “With all due respect…” • “Would you permit me to express how I feel about that?”

36. Implementing CBT withLatino Youth:Positive Ethnic ID • Bandura (1982): An individual must acquire skills to master the environment to develop a sense of positive self-worth and effectiveness. • Bibliotherapy – helps youth learn about positive role models of their own group (I Am Latino) • Involvement in political activity or Latino youth groups • Use of racial socialization in therapy • Learn to label racism accurately, identify it when it occurs, and understand the experience. • Parent used as a role model to demonstrate how to handle situations • Provide emotional support for the justified anger • Assist parents in not reinforcing negative racial stereotypes by sharing more positive racial images

37. Future Directions • Training programs need to improve preparation of clinicians to work with culturally diverse populations IN ADDITION to training them in evidence-based treatments • Clinical CBT supervisors need to be willing to examine their own values, beliefs, attitudes, and worldviews • Cultural issues need to be raised in supervision • Need to consider culture as an inherent part of multiaxial diagnostic assessment

38. Future Directions • Research must focus on culturally sensitive assessment and treatment response of Latinos to traditional CBT as well as culturally-adapted protocols • Move away from cross-cultural comparisons and focus on one ethnic group at a time

39. Conclusion & Discussion • IT IS POSSIBLE to provide culturally responsive CBT to Latino youth and families. • CBT clinicians need to incorporate diversity issues into treatment plans.