Ten Steps to Culturally Competent Evidence-Based Practice Pamela A. Hays, Ph.D. www.drpamelahays.com 9/19/2018

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 9/19/2018

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 9/19/2018

Historical/Cultural Development Psychoanalysis Behaviorism Family systems Humanistic/Existential/ Feminist CBT Multicultural 9/19/2018

Behavioral Principles Emphasis on here & now. Person X Environment = Behavior All behavior is learned. 9/19/2018

Behavioral Principles… Adapt methods to each person’s situation, needs, & strengths. Set clearly defined achievable goals. Ongoing assessment. 9/19/2018

5 Components of CBT Environment/Situation Emotions Sensations Behaviors Cognitions 9/19/2018

Environment 9/19/2018

CBT: Problem Conceptualization A. Environmental/External B. Cognitive/Internal --overwhelming emotions --disturbing physical sensations --self-defeating behaviors --unhelpful thoughts/images 9/19/2018

Problem Type Intervention Envir./External Cog./Internal Problem-solving Environmental changes Support groups Behavioral skill building Assertiveness training Relaxation training Modeling, reinforcement Competing behaviors Cognitive restructuring 9/19/2018

Cognitive Restructuring (def.) --involves changing unhelpful thoughts and images to more helpful ones, to manage overwhelming emotions & physical sensations, and change self-defeating behaviors. 9/19/2018

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. 9/19/2018

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. 9/19/2018

The ADDRESSING Framework Cultural Influences Minority 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 9/19/2018

Two Categories of Work Personal Interpersonal 9/19/2018

Essential Knowledge 1. Bias is best thought of as a tendency to think, act, or feel in a particular way. 9/19/2018

Understanding Bias Generalizations Biases & Biases  Worldview Categorizations Biases 9/19/2018

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. 9/19/2018

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 9/19/2018

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. 9/19/2018

Use ADDRESSING framework to generate Strengths & Supports List. 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? 9/19/2018

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 9/19/2018

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 9/19/2018

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 9/19/2018

3. Consider Cultural Influences on the 5 Components of CBT: Environment Emotions Sensations Behaviors Cognitions 9/19/2018

Environment + Cultural considerations Recognize cultural influences in the environment Acknowledge oppressive aspects of the situation Validate client’s personal experience of oppression 9/19/2018

Emotions + Cultural Considerations Consider differences in emotional expressiveness Consider differences in reporting emotion 9/19/2018

Sensations + Cultural Considerations Consider somatic expressions of distress Consult with physician regarding somatic complaints. 9/19/2018

Behavior + Cultural Considerations Recognize that culture shapes all behaviors. Be familiar with culture-bound syndromes. 9/19/2018

Cognition + Cultural Considerations Consider cultural values that affect perceived options. Consider cultural norms (beliefs) including different definitions of rationality, adaptive/maladaptive behavior, & health. 9/19/2018

a. Validate experiences of oppression. CR-CBT… 4. Clarify what part of the problem is primarily external & what part is primarily internal. a. Validate experiences of oppression. 9/19/2018

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 9/19/2018

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). 9/19/2018

7. Be cautious about the Downward Arrow Technique 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?”) 9/19/2018

CR-CBT… 8. Do not challenge a core cultural belief unless client is open to this. 9/19/2018

CR-CBT… 9. Use Culturally Related Strengths & Supports List to generate more helpful thoughts & images. 9/19/2018

10. Develop culturally congruent homework that emphasizes CR-CBT… 10. Develop culturally congruent homework that emphasizes client direction. 9/19/2018

Culturally Responsive CBT 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. 9/19/2018

A major obstacle to Culturally Competent Evidence-Based Practice is DEFENSIVENESS. 9/19/2018

What led to your defensive feelings? 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? 9/19/2018

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 ). 9/19/2018

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. 9/19/2018

Resolving Value Conflicts Look for the shared value. Recognize differences in value priorities. Reframe differences using positive language. 9/19/2018

Reframing Value Differences 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 9/19/2018