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

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
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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
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4. Historical/Cultural Development
Psychoanalysis
Behaviorism
Family
systems Humanistic/Existential/
Feminist
CBT
Multicultural
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5. Behavioral Principles
Emphasis on here & now.
Person X Environment = Behavior
All behavior is learned.
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6. Behavioral Principles…
Adapt methods to each person’s situation, needs, & strengths.
Set clearly defined achievable goals.
Ongoing assessment.
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7. 5 Components of CBT Environment/Situation Emotions Sensations
Behaviors
Cognitions
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8. Environment
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9. CBT: Problem Conceptualization
A. Environmental/External
B. Cognitive/Internal
--overwhelming emotions
--disturbing physical sensations
--self-defeating behaviors
--unhelpful thoughts/images
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10. 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
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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.
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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.
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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.
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14. 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
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15. Two Categories of Work
Personal
Interpersonal
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16. Essential Knowledge 1. Bias is best thought of as a tendency to
think, act, or feel in a particular way.
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17. Understanding Bias Generalizations Biases & Biases  Worldview
Categorizations Biases
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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.
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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
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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.
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21. 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?
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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
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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
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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
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25. 3. Consider Cultural Influences on the 5 Components of CBT:
Environment
Emotions
Sensations
Behaviors
Cognitions
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26. 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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27. Emotions + Cultural Considerations
Consider differences in emotional expressiveness
Consider differences in reporting emotion
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28. Sensations + Cultural Considerations
Consider somatic expressions of distress
Consult with physician regarding somatic complaints.
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29. Behavior + Cultural Considerations
Recognize that culture shapes all behaviors.
Be familiar with culture-bound syndromes.
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30. 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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31. 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.
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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
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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).
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34. 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?”)
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35. CR-CBT…
8. Do not challenge a core cultural belief unless client is open to this.
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36. CR-CBT…
9. Use Culturally Related Strengths & Supports List to generate more helpful thoughts & images.
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37. 10. Develop culturally congruent homework that emphasizes
CR-CBT…
10. Develop culturally congruent
homework that emphasizes
client direction.
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38. 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.
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39. A major obstacle to Culturally Competent Evidence-Based Practice is DEFENSIVENESS.
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40. 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?
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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 ).
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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.
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43. Resolving Value Conflicts
Look for the shared value.
Recognize differences in value priorities.
Reframe differences using positive language.
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44. 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
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