CULTURAL SENSITIVE PSYCHOTHERAPY AND PTSD

CULTURE & PSYCHOTHERAPY

Prof. Dr. Dr. Jan Ilhan Kizilhan

Asmaa Ibrahim M. Salih (MSc, Psych.)
The Need for Culturally and Psychotherapy

Why?
Need for a Culturally Adapted Approach

• Please view the following video1.

http://youtu.be/IGQmdoK_ZfY

• Without cultural competence we may focus on the

therapeutic “game” as we know it, missing the gorilla of
culture in the middle.

• May also miss the importance of context (the curtains)

and the working alliance could also be affected (i.e. a
player leaving the game).

1:
Simmons (2010)
One Size Fits All?

• Clinicians and administrators are presented with the

problem of having to “fit” existing Evidence Based
Treatments (EBT) to their patients with little
guidance on standards for adaptation for culture,
language, and context.

• Achieving a balance between culturally competent

practice and selection of interventions that are
scientifically rigorous is especially challenging when
delivering interventions to ethno-cultural groups
(ECG).
Fitting the Data to the Model

• Greek Mythology
Procrustean Fit – Early example
(fitting person to the model)

• The reasonable alternative is to

adapt, modify, or tailor the
model
Fitting the Model to the Data

In the case of psychotherapy:

• The adaptation should retain the essence (key
theoretical constructs, theory of change, and basic
procedures) of the model; yet the model of adaptation
should take into consideration the unique
characteristics of the population being served.

• Some suggest that we develop a new therapy for each

and every patient.
What are Adaptations?

Changes to treatment content or process that include

• Additions, enhancements, or deletions

• Alterations to the treatment components
• Changes in the intensity of the treatment
• Cultural or other contextual modifications
History of Psychotherapy Adaptations

• Psychotherapy has a long history of adaptations

• Setting
• From the couch to the chair to the phone and the Web
• Intensity
• 4-5 session @ week - to 1 session @ week
• Structure
• From Individual to Group, to Family, Couples, Networks
• Adaptations respond to changing socio-cultural context
Cultural Adaptation

The systematic modification of an EBT or intervention

protocol to consider language, culture, and context in
such a way that it is compatible with the client’s cultural
patterns, meanings, and values.

(Bernal, Jiménez-Chafey, & Domenech Rodríguez, 2009)

Approach to Cultural Adaptations of EBTs

• Some researchers suggest there should be flexibility

with EBTs within a framework of fidelity so that
adaptations may be made
(Kendall & Beidas, 2007)

• Others have called for systematic adaptations to

manuals and protocols such that culture, language,
and socio-economic contexts are explicitly considered
(Hall, 2001; Sue, Bingham, Porche-Burke, &
Vásquez, 1999; Trimble & Mohatt, 2002)
Reasons for Culturally Adapting Interventions

1. Singularity - Specificity Argument

2. Ecological Validity Argument
3. Evidentiary Argument
4. Feasibility-Practicality Argument
5. Science Argument
6. Ethical Argument
Singularity - Specificity Argument

• Treatments need to be made specific to group culture

• Values of subjective culture need to be considered in
treatment of ethnic minorities
(Bernal, Bonilla & Bellido, 1995)

• Culture and context influences almost every aspect of the

diagnostic and treatment process
(Alegría & McGuire, 2003; Canino & Alegría, 2008; Comas-Díaz, 2006)

• Three common constructs found to differentiate ethnic

minority from majority persons in the US:
• inter-dependence, spirituality, discrimination
(Hall, 2001)
Ecological Validity Argument

External Validity

• Is the environment as experienced by the

patient/client the same as the therapist assumes it is
experienced in treatment?

• Most EBTs are conducted with White, educated,

verbal, and middle class patients and may not
generalize to ethnic minority and Third World
communities
(Bernal & Scharrón-del Río, 2001)
Ecological Validity Argument

Social Validity
• Acceptability and viability of the intervention by the
community

• Evidence that some communities may respond poorly

to EBP approaches (Lau, 2006)
• Attrition
• Marginal participation
• Barriers to engagement
Evidentiary Argument

• Little empirical evidence that EBTs are effective with

minority populations (Hall, 2001; Sue, 1998).
• Few efficacy studies to guide treatment and research with
ethnic minorities (Miranda et al., 2005).
• Some literature suggests that EBT for Parent management
training, ADHD, and depression care may generalize to
Latino and African Americans (Miranda, et al. 2005).

• Studies on service utilization, treatment preference,

and health beliefs suggest that ethnic minorities may
respond differently to psychotherapy (Bernal & Scharron
del Río, 2001).
Feasibility-Practicality Argument
Ethical Argument

• Psychotherapists have an ethical responsibility to

offer the best possible treatment by taking into
account the values, culture, and context of their
patients (Trimble & Mohatt, 2002).

• Ethical considerations about beliefs and values of

the members of the cultural groups being targeted
for interventions are as powerful as questions
related to science.
Psychotherapy Adaptation and Modification
Framework (Hwang, 2006)
Six domains:
• Dynamic Issues
• Cultural Complexities
• Orientation
• Cultural beliefs
• Client-therapist relationship
• Cultural differences in expression and communication
• Cultural issues of salience
First Summary and Conclusions

• One size does not fit all

• Through cultural adaptations it may be possible to go beyond the one-
size-fits-all approach and move closer toward the ideal of providing
effective psychotherapies for all individuals that is contextualized in
terms of cultural values, language, and socio-economic status, gender,
and preferences.

• Adaptations that are well documented, systematic, and tested

can advance research and inform practice.
• Psychotherapy adaptation models/frameworks are useful in guiding
cultural adaptations.
• Research with ethnic minorities has shown that there are definite
differences in responses to therapy, as well as in engagement and
retention.
Conclusion

Culturally adapting psychotherapy is a

viable and ethical option!
 PSYCHIATRY

EXTREME CULTURAL EXTREME

RELATIVISM
UNIVERSALISM

UNIVERSALISM: Mental disorders are

essentially the same
throughout the world.
RELATIVISM: One is crazy in relation to a
given society
 CULTURAL PSYCHIATRY

 Common Psychological substrate

 Feelings / Common Sufferings
 Different expression
 Different interpretation
CULTURAL PSYCHIATRY

• To what extent the medical symptom, diagnosis or

psychiatric practice are a reflection of social, cultural and
moral concerns.
• Get it over with duality biology vs. culture.
• Cultural biology: culture is a biological category.
• Biology is heavily influenced by genetics, environment,
diet ...
 EVOLUTION OF CULTURAL PSYCHIATRY

- Culture is dynamic and is inextricably linked to the social context of

the patient.
- Exclusive ethnic minorities ??
- Inherently multidisciplinary:
Psychiatric epidemiology
Medical Anthropology
Cognitive and social psychology
Neurosciences
- Addressing the psychological processes not as a purely
individual but include your speech into something social

- Critical view of the interaction of the structures of knowledge and

power
(L.Kirmayer, H.Minas)
 CHALLENGES OF MULTICULTURALISM
COMPETENCIA CULTURAL
IN MENTAL HEALTH CARE

Current situation with immigrants:

 Underutilization of services
 High levels of discontinuity
 Poor adherence
 Poor results
 Misdiagnoses
 Inadequate treatment
Case: Cultural Formulation

Cultural identity of individual

Cultural explanation of illness
Psychosocial environment
Therapeutic relationship
Overall cultural assessment for dx/care
What is Culturally Competent?

1
Sue, Arredondo, & McDavis (1992, p.481); 2Sue & Sue (2008); 3Sue et al. (1982); 4Collins & Arthur (2010, p.210)
Professional Guidelines
• American Psychological Association’s 6 general guidelines1:

1
American Psychological Association (2002)
 CLINICAL CULTURAL COMPETENCE

• Dimensions
 Knowledge (What To Know)
 Skills (How to do…)
 Attitudes (How to be…)
 KNOWLEDGE

What must the clinician know in order to

• Diagnose the patient?
• Treat the patient?

• Discussion
 KNOWLEDGE

Cultural and social aspects

Concept of problem
Finding Help
Living conditions
Aspects related to immigration
Explanatory models
Meaning and Context
"Idioms of distress"
Notions of ethnopharmacology
Cultural Formulation Interview

Cultural Formulation Interview, DSM-5, (interviewer and

informant versions with 12 modules).

(Collaborate with WHO for ICD 11)

Should precede the standard diagnostic interview.

Designed to be used with EVERYONE!

32
Cultural Formulation Interview

Cultural Definition of the Problem

What do you
think are the Stressors and Supports
causes?

Role of Cultural Identity

33
Cultural Perceptions of Cause … Stressors … Supports

Stresses… money
… family
How would you describe
your problem?

resources, social
supports, and resilience

spiritual reason

kinds of support that help … support

from friends, family…
34
Role of Cultural Identity

communities you belong race … ethnic background …

to …. languages you gender … sexual orientation …
speak… faith … religion

homelessness migration-related problems

as culture

We all have multiple

identities!
discrimination due to … ?
conflict across generations?
35
Cultural Identity

• Ethnicity • Experiences
• Race • Education
• Country of origin • Other identified groups
• Language • Sexual orientation
• Gender • Migration/Flight/War/Terror
• Age history
• Marital status • Level of acculturation/adaption
• Religious/ spiritual beliefs
Personality

• Addressing personality,
culture, and universal
needs / motives are all
part of a holistic
conceptualization of the
client and their
challenges1–4.

Leong (1996); 2Leong (2007); 3Sue & Sue (2008); 4Hofstede, Hofstede & Minkov (2010)
1
The “Big 5”of Personality1

• The ‘universal’ big five/five factor

model of personality has been
validated across more than 50
cultures1,2 but there are
considerable aggregate
personality differences in traits

• Comparing People in Kurdistan to

other group can help us
understand ourselves in context

1
McCrae, Yik, Trapnell, Bond, & Paulhus (1998); 2McCrae & Terracciano (2005a)
Explanatory Models
• Moral
• Moral defect: lazy, selfish, weak will
• Try fix character flaw: “just have to work harder”
• Spiritual/ religious
• Transgressions—”angered higher power”
• Interventions—atonement/ religious leader
• Magical
• Hex/ sorcery/ witchcraft
• find person caused/ healer
• Medical—biological model
• Psychological conflict
Therapeutic Relationship

Cultural elements of relationship between individual &

clinician
Own cultural background
Patient’s cultural identity
Parent’s cultural identity
Move from categorical approach
Ongoing assessment
Transference/ counter-transference
Consider cultural consult
Patient’s motivation for treatment
Interpreters

• Verbal/ non-verbal communication

• Types interpretation
• Verbatim
• Summary
• Cultural
• 3 phases interpreted interview
• Pre-interview
• Interview
• Post-interview
Assessment Tools

• Normed on ethnic minorities?

• Translation not sufficient
• Languages have different
• Meanings
• Connotations
• Idioms of expression
• Rating scales may be used if
• Translated/ back-translated/ validated
Clinician’s Role

• Clinicians who have clarity about their own

• Cultural identity
• Role in mental health treatment
• Better position to anticipate problematic cultural dynamics of
clinical exchange
• Decrease negative outcomes
• Enhance positive outcomes
Therapeutic Relationship

• Interethnic Transference
• Patient’s response to an ethno-culturally different clinician
• Interethnic Counter-transference
• Ethno-culturally different clinician may respond in non-therapeutic
manner
• Denial of cultural influence on clinical encounter
Cultural Influences On Transference

Interethnic effects Intraethnic effects

• Overcompliance • Omniscient-omnipotent
• Deny ethnocultural factors therapist
• Mistrust • The traitor
• Hostility • Autoracism
• ambivalence • ambivalence

How it is in Kurdistan?
Self-Coping

treatment, help, advice, healing ….

most useful … least helpful doctors, helpers, healers

folk healing, spiritual counseling,

alternative healing, support groups

46
Barriers

money, work, family

stigma, shaming,
discrimination

lack of services that understand your

what got in
background
the way?

47
Preferences

What do you think would be

most useful?
social network views

What have family, friends

suggested?

48
CFI function provided by 12 supplementary modules to use in
subsequent sessions

1. Explanatory Model
2. Level of Functioning
3. Social Network
4. Psychosocial Stressors
5. Spirituality, Religion, and Moral Traditions
6. Cultural Identity
7. Coping and Help-Seeking
8. Patient–Clinician Relationship
9. School-Age Children and Adolescents
10. Older Adults
11. Immigrants and Refugees
12. Caregivers

49
 CULTURE IN DSM-V
CULTURAL FORMULATION
 CULTURE IN DSM-V
CULTURAL FORMULATION
• Groupwork:

Go trough CFI and tried to adapted this in your own culture

 Cultura en el
CULTURE in DSM-5
DSM-5
• The key point is making changes that strengthen the cultural
validity of the diagnoses in practice.
• Inclusion of culture in the DSM-5
▫ Section I: Introduction
▫ Section II: Disorders
▫ Section III: Cultural Formulation
▫ Appendix: Glossary of Cultural Concepts of Distress
▫
 Maximum haloperidol concentration
after administration of 0.5 mg (im)

5
Haloperidol in serum (ng)

Asiatic Caucasian
Keh-Ming Lin, MD, MPH
Harbor-UCLA Research & Education Institute,
Torrance, CA
Orientation to Therapy: Overview

• Providing an orientation and explanation to the

expectations of and unique ‘culture’ of therapy.

• Changing structure and focus of sessions to be

more in line with client expectations

1
Hwang (2006)
Orientation:

• Make time for a longer, more detailed orientation1,2

• Educate explicitly about roles and expectations in therapy

• Explain the typical course of therapy

• Build rapport by emphasizing confidentiality, 3

• Discuss healthy therapeutic termination to reduce dropout1

• Reduce stigma by articulating a holistic / biopsychosocial model

that doesn’t make the client feel personally blamed for their
illness 1,4
1
Hwang (2006); 2Hwang (2009); 3Sue & Sue (2008); 4Hays (2009)
Responding to Expectations:

• Consider a more directive, active, expert approach preferred

by most cultural groups1–7

• Problem-focused, time-limited approaches (CBT, BT, SFT) often

fit well with more concrete expectations of diverse clients2

1
Sue & Zane (1987); 2Sue & Sue (2008); 3Lafromboise, Trimble, & Mohatt (1990), 4Al-Krenawi & Graham (2000), 5Li & Kim (2004);
6
Kim, Li, &, Liang (2002); 7Rossello, Bernal, & Rivera-Medina (2008)
Responding to Expectations:

• Directly address clients receiving less initial benefits

due to acclimatization time to foreign therapeutic
culture / waiting longer to seek help1

• Offer the gift of a small solution early on as an

example and to provide motivation2

• Being more directive does not mean being

paternalistic3 this can remind clients of historical and
current oppression

1
Hwang (2009); 2 Sue (1998); 3Gonzalez-Prendes, Hindo, & Pardo (2011)
Establishing Goals/Structure:

• Emphasize co-constructing therapy1:

• Be directive and explicitly structure sessions
• Give guidelines of responses expected
• Emphasize client’s role as expert in their life
• Provide a choice of activities
• Encourage development of own solutions
• Look to the client to set treatment goals

• Focus on alleviating symptoms1

• Establish frequent goals and markers of treatment progress

with periodic review to appeal to concrete-oriented clients2
Sue & Sue (2008); 2Hwang (2009)
1
Cultural Beliefs:

• Understanding cultural beliefs about illness and

treatment

• Integrating cultural systems, beliefs, meanings,

and strengths to enhance treatment

• Maintaining awareness and responsiveness to how

beliefs affect help-seeking and treatment
preferences

1
Hwang (2006)
Cultural Beliefs:

• Facilitates client understanding and adherence to treatment

• Increases client comfort

• Makes treatment more culturally congruent

• Takes advantage of existing strengths and healing pathways

• Addresses the stigma of counselling by presenting a familiar

cultural model

• May enhance the perceived relevance, recall, and behaviour

change from therapeutic concepts3

Hwang (2006); 2Hwang(2009); 3Otto (2000)

1
Holistic, Psychoeducational Approach:

• Educate clients in a biopsychosocial model of mental

illness that does not place the blame solely on the
client and their cognitions1,2

• Maintain a more systemic focus, especially with

clients who identify with collectivistic values or
struggling with societal prejudice3

• Help resolve relational/social conflicts2,4

Hwang (2006); 2Hays (2009); 3Sue & Sue (2008, pp.180, 254, 256); 4Hwang (2009)
1
Holistic, Psychoeducational Approach:

• Explicitly explore the consequences of interventions

for the client’s whole family1

• Simplify material, reduce learning load, consolidate

complex topics2

• Increase time for teaching unfamiliar concepts2,

consider increasing session length if necessary

1
Sue & Sue (2008, p.370); 2Hwang (2009)
References
Barrera, M., & González-Castro, F. (2006). A Heuristic framework for the cultural adaptation of interventions. Clinical Psychology: Science
and Practice, 13, 311-316.
Bernal,G., Jiménez-Chafey, Domenech Rodríguez, M. (in press) Cultural Adaptation of Evidence-based Treatments for Ethno-cultural Youth,
Professional Psychology: Research and Practice.
Domenech-Rodríguez, M., & Weiling, E. (2004). Developing culturally appropriate, Evidence-Based Treatments for interventions with ethnic
minority populations. In M. Rastogin & E. Weiling (Eds.), Voices of Color: First person accounts of ethnic minority therapists. (pp. 313-
333). Thousand Oaks: Sage Publications.
Griner, D. Smith, T. (2006) Culturally adapted mental health intervention: A meta-analytic review. Psychotherapy: Theory, Research,
Practice, Training, 43(4),531-548.
Hall, G. C. N. (2001). Psychotherapy research with ethnic minorities: Empirical, ethical, and conceptual issues. Journal of Consulting and
Clinical Psychology, 69, 502-510.
Huey, S. J., & Polo, A. J. (2008). Evidence-based psychosocial treatments for ethnic minority youth: A review and meta-analysis. Journal of
Clinical Child and Adolescent Psychology, 37, 262-301.
Hwang, W. (2006). The Psychotherapy Adaptation and Modification Framework: Application to Asian Americans. American Psychologist, 61,
702-715.
Hwang, W. (2011). Cultural adaptations: A complex interplay between clinical and cultural issues. Clinical Psychology: Science and Practice,
18, 238–241. doi:10.1111/j.1468-2850.2011.01255.x
Hwang, W. (2012). Integrating top-down and bottom-up approaches to culturally adapting psychotherapy: Application to Chinese
Americans. In G. Bernal & M. M. Domenech Rodriguez (Eds.), Cultural Adaptations: Tools for Evidence-Based Practice with Diverse
Populations (pp. 179–199). American Psychological Association Press.
Lau, A. S. (2006). Making the case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent
training. Clinical Psychology: Science and Practice, 13, 295-310.
Hofstede, G., Hofstede, G. J., & Minkov, M. (2010). Cultures and organizations: Software of the mind, 3rd ed. New York: McGraw-Hill.
Sue D. W., Bucceri, J., Lin, A. I., Nadal, K. L., & Torino, G. C. (2007). Racial microaggressions and the Asian American experience. Cultural
Diversity and Ethnic Minority Psychology, 13, 72–81. doi:10.1037/1099-9809.13.1.72