1. University of Wisconsin-Milwaukee
Strategies for Delivering Behavioural Activation in Diverse Communities
Jonathan Kanter, Ph.D.
University of Wisconsin-Milwaukee

2. Develop adaptations of treatment for various cultural groups
Empirically demonstrate need for adaptation
NIMH policy:
Assume culture matters

3. Problem: Results in too many cultural adaptations, not viable at public health level
Empirically demonstrate need for adaptation
NIMH policy:
Assume culture matters

4. Problem: Results in too many cultural adaptations, not viable at public health level
Empirically demonstrate need for adaptation
NIMH policy:
Assume culture matters

5. Problem: Not a progressive or fair solution
Empirically demonstrate need for adaptation
NIMH policy:
Assume culture matters

6. Our solution: Create culturally flexible version of BA by removing mainstream cultural elements from it
Empirically demonstrate need for adaptation
NIMH policy:
Create more “culture-neutral” treatment

7. Again, need to learn lots of content
Problems:
Again, need to learn lots of content
May encourage stereotyping, does not teach clinician how to adapt to the individual
Empirically demonstrate need for adaptation
NIMH policy:
Train culturally competent clinicians

8. Our solution:
Train process of assessing and working in client’s local cultural world
Specific cultural content is still important and can be trained locally
Train how to assess client’s local cultural world
NIMH policy:
Train culturally competent clinicians

9. BA Training Sequence I II III Cultural competence process
Providing the Rationale
Assessment
Activity Scheduling
Dealing with Avoidance II
Functional Assessment
Skills training
Stimulus control
Contingency management
III
Behavioral case conceptualization
Thinking functionally about behavior

10. BA Training Sequence I II III Cultural competence process
Providing the Rationale
Assessment
Activity Scheduling
Dealing with Avoidance II
Functional Assessment
Skills training
Stimulus control
Contingency management
III
Behavioral case conceptualization
Thinking functionally about behavior

11. Cultural Competence Process
“Shifting Cultural Lenses” model of Steven López, University of Southern California
Develop a Shared Narrative

12. Assess client’s view
Ask client what hopes to gain from tx
Ask what client views as problem
Assess how client fits cultural patterns
Show understanding without challenging
Present own perspective
Introduce BA as personal view, not fact
Ask for feedback, clarify
Ask how view fits client’s understanding
SN: Integrate
Fit client’s narrative into BA model using his/her language (see next)
SN: Ask for buy-in
Ask client to try model with respect and collaboration
SN: Negotiate
Demonstrate willingness to drop BA model

13. Assess client’s view
Ask client what hopes to gain from tx
Ask what client views as problem
Assess how client fits cultural patterns
Show understanding without challenging
Present own perspective
Introduce BA as personal view, not fact
Ask for feedback, clarify
Ask how view fits client’s understanding
SN: Integrate
Fit client’s narrative into BA model using his/her language (see next)
SN: Ask for buy-in
Ask client to try model with respect and collaboration
SN: Negotiate
Demonstrate willingness to drop BA model

14. Assess client’s view
Ask client what hopes to gain from tx
Ask what client views as problem
Assess how client fits cultural patterns
Show understanding without challenging
Present own perspective
Introduce BA as personal view, not fact
Ask for feedback, clarify
Ask how view fits client’s understanding
SN: Integrate
Fit client’s narrative into BA model using his/her language (see next)
SN: Ask for buy-in
Ask client to try model with respect and collaboration
SN: Negotiate
Demonstrate willingness to drop BA model

15. Assess client’s view
Ask client what hopes to gain from tx
Ask what client views as problem
Assess how client fits cultural patterns
Show understanding without challenging
Present own perspective
Introduce BA as personal view, not fact
Ask for feedback, clarify
Ask how view fits client’s understanding
SN: Integrate
Fit client’s narrative into BA model using his/her language (see next)
SN: Ask for buy-in
Ask client to try model with respect and collaboration
SN: Negotiate
Demonstrate willingness to drop BA model

16. Assess client’s view
Ask client what hopes to gain from tx
Ask what client views as problem
Assess how client fits cultural patterns
Show understanding without challenging
Present own perspective
Introduce BA as personal view, not fact
Ask for feedback, clarify
Ask how view fits client’s understanding
SN: Integrate
Fit client’s narrative into BA model using his/her language (see next)
SN: Ask for buy-in
Ask client to try model with respect and collaboration
SN: Negotiate
Demonstrate willingness to drop BA model

17. Assess client’s view
Ask client what hopes to gain from tx
Ask what client views as problem
Assess how client fits cultural patterns
Show understanding without challenging
Present own perspective
Introduce BA as personal view, not fact
Ask for feedback, clarify
Ask how view fits client’s understanding
SN: Integrate
Fit client’s narrative into BA model using his/her language (see next)
SN: Ask for buy-in
Ask client to try model with respect and collaboration
SN: Negotiate
Demonstrate willingness to drop BA model

18. “THREE CIRCLES” Shut down, give up Procrastinate Stay at home
Use clients’ descriptions
No need to educate about “symptoms” of depression
Response
(Natural, common)
Avoidance Pattern
(Natural, common)
Feeling sad, down, depressed
Loss of interest or pleasure in things
Stress, headaches, pain, fatigue, anger, irritability
Spiritual questioning/doubts
Guilt and shame
Changes in sleep and appetite
Difficulties with concentration and memory
Shut down, give up
Procrastinate
Stay at home
Stop functioning
Sleep too much
Ruminate
Drink too much Watch tv
NEGATIVE
LIFE EXPERIENCES

19. “THREE CIRCLES”
Response
(Natural, common)
ACTIVATION
Use your strengths and social support to stay active, reengage in life, solve problems
Activate religious coping as appropriate
Incorporate family in activation
Free, low cost activities
Use community resources
NEGATIVE
LIFE EXPERIENCES

20. “THREE CIRCLES”
Response
(Natural, common)
ACTIVATION
Improved Life

21. “THREE CIRCLES” MODEL OF BA
Did the therapist… 1
Identify and discuss negative life experiences? 2
Identify and discuss emotional responses (feelings)? 3
Identify and discuss behavioral responses (actions, secondary coping, avoidance)? 4
Validate emotional and behavioral responses as natural, normal, common (matter of fact)? 5
Discuss how responses lead to more negative life experiences? 6
Explain the goal of BA: activation as alternative to natural responses (“breaking the cycle”)?

22. Challenges when Presenting the Rationale
Just DO IT!
Validate that activation is harder than people think
Discuss that therapist will coach, guide with strategies to help activation
Inside Out
Validate that inside-out is common and makes sense
Offer rationale for outside-in approach in BA
Broken Brain
Validate many causes of depression
Explain how activation can change the brain

23. Challenges when Presenting the Rationale
Just DO IT!
Validate that activation is harder than people think
Discuss that therapist will coach, guide with strategies to help activation
Inside Out
Validate that inside-out is common and makes sense
Offer rationale for outside-in approach in BA
Broken Brain
Validate many causes of depression
Explain how activation can change the brain

24. Challenges when Presenting the Rationale
Just DO IT!
Validate that activation is harder than people think
Discuss that therapist will coach, guide with strategies to help activation
Inside Out
Validate that inside-out is common and makes sense
Offer rationale for outside-in approach in BA
Broken Brain
Validate many causes of depression
Explain how activation can change the brain

25. Challenges when Presenting the Rationale
Just DO IT!
Validate that activation is harder than people think
Discuss that therapist will coach, guide with strategies to help activation
Inside Out
Validate that inside-out is common and makes sense
Offer rationale for outside-in approach in BA
Broken Brain
Validate many causes of depression
Explain how activation can change the brain

26. Questions Practice