Abstract
In increasingly multicultural societies, cognitive behavioral therapy (CBT) needs to be made appropriate for diverse groups. Refugees with mental health difficulties present particular therapeutic challenges that include complex trauma, different cultural traditions, and ongoing stress. The current chapter outlines how a contextually sensitive CBT can be developed for such refugee groups. It outlines key dimensions of culturally sensitive CBT, which can be therapeutically implemented among refugees in order to maximize efficacy and effectiveness. These guidelines can be followed to design culturally sensitive CBT studies among refugees, or what might be called “contextually sensitive CBT,” and the guidelines can be used to evaluate such studies. Some examples of these key dimensions of care are the following: assessing and addressing key local complaints (e.g., somatic symptoms, spirit possession, and syndromes like “thinking a lot”); incorporating into treatment key local sources of recovery and resilience (e.g., CBT-compatible proverbs and techniques in that culture). Another example of a key dimension of care is making CBT techniques more tolerable and effective for the cultural group through various means: by using a phased approach, by utilizing culturally appropriate framing of CBT techniques (using local analogies), by making positive re-associations to problematic sensations during interoceptive exposure (e.g., to traditional games), and by using trauma-type exposure as an opportunity to practice emotion regulation. We describe such concepts as explanatory model bridging, cultural grounding, and contextual sensitivity.
Keywords
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- 1.
Interoceptive exposure is a cognitive behavioural therapy technique used in the treatment of panic disorder in which the individual is exposed to interoceptive sensations like dizziness to decrease fear of them.
- 2.
In many Buddhist countries symptoms may be attributed to bad spiritual status. If the client thinks the current state is due to “low merit” or past bad actions (“bad karma”), the client can be encouraged to use cultural means to elevate spiritual status. As such, meditating or projecting loving kindness are considered merit-making and by doing these activities, the client regains a sense of agency (there is a transformation of self-image). Thus, the client engages in a practice that is therapeutic by both local and “scientific” standards. Note that addressing concerns about a depleted or inauspicious spiritual status is often part of addressing catastrophic cognitions because the perception of low spiritual power and thus great vulnerability leads to multiple types of catastrophic cognitions: that spirit attack may lead to sleep paralysis and that somatic symptoms are due to invasion by a spirit.
- 3.
The attempt at bridging, which requires eliciting the client’s explanatory model, is seemingly efficacious for various reasons: increasing positive expectancy and credibility by increasing the client’s feeling that the therapist’s understands their concerns and by identifying catastrophic cognitions about symptoms (Hinton, Lewis-Fernández, et al., 2016). A recent review indicated that cultural adaptation of treatment increased effect size, and that the key aspect of cultural adaptation was eliciting the client’s explanatory model of disorder (Benish et al., 2011).
- 4.
In respect to trauma, one may need to address social blaming and self-blaming: a rape victim may be blamed and stigmatized. In many Asian countries, the concept of karma (i.e., the idea that what happens to one is a result of past bad actions and so is deserved) can lead to a blaming of the victim. It should be noted that local models like that of karma may be used as a justificatory frame for perpetration of violence and need to be addressed at the community level. More generally, stigmatization of the survivor may need to be addressed at various levels such as through finding group consensus and utilizing local religious and transnational human-rights frames.
References
Agger, I., Igreja, V., Kiehle, R., & Polatin, P. (2012). Testimony ceremonies in Asia: Integrating spirituality in testimonial therapy for torture survivors in India, Sri Lanka, Cambodia, and the Philippines. Transcultural Psychiatry, 49(3–4), 568–589.
Amer, M., & Jalal, B. (2011). Individual psychotherapy/counseling: Psychodynamic, cognitive behavioral and humanistic-experiential models. In S. Ahmed & M. Amer (Eds.), Counseling Muslims: Handbook of mental health issues and interventions (pp. 87–117). New York, NY: Routledge.
Bass, J. K., Annan, J., McIvor Murray, S., Kaysen, D., Griffiths, S., Cetinoglu, T., … Bolton, P. A. (2013). Controlled trial of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine, 368(23), 2182–2191.
Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology, 58(3), 279–289.
Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. D. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40(4), 361–368.
Bolton, P., Michalopoulos, L., Ahmed, A. M., Murray, L. K., & Bass, J. (2013). The mental health and psychosocial problems of survivors of torture and genocide in Kurdistan, Northern Iraq: A brief qualitative study. Torture, 23(1), 1–14.
Bolton, P., Surkan, P. J., Gray, A. E., & Desmousseaux, M. (2012). The mental health and psychosocial effects of organized violence: A qualitative study in northern Haiti. Transcultural Psychiatry, 49(3–4), 590–612.
Casey, B. J., Craddock, N., Cuthbert, B. N., Hyman, S. E., Lee, F. S., & Ressler, K. J. (2013). DSM-5 and RDoC: Progress in psychiatry research? Nature Reviews: Neuroscience, 14(11), 810–814.
Chisholm, D., Flisher, A. J., Lund, C., Patel, V., Saxena, S., Thornicroft, G., & Tomlinson, M. (2007). Scale up services for mental disorders: A call for action. The Lancet, 370(9594), 1241–1252.
Crumlish, N., & O’Rourke, K. (2010). A systematic review of treatments for post-traumatic stress disorder among refugees and asylum-seekers. Journal of Nervous and Mental Disease, 198(4), 237–251.
de Jong, J. T., Komproe, I. H., Spinazzola, J., van der Kolk, B. S., & van Ommeren, M. H. (2005). DESNOS in three postconflict settings: Assessing cross-cultural construct equivalence. Journal of Traumatic Stress, 18(1), 13–21.
de Jong, J. T., & Reis, R. (2010). Kiyang-yang, a West-African postwar idiom of distress. Culture, Medicine, and Psychiatry, 34(2), 301–321.
de Jong, J. T., & Reis, R. (2013). Collective trauma resolution: Dissociation as a way of processing post-war traumatic stress in Guinea Bissau. Transcultural Psychiatry, 50(5), 644–661.
Drozdek, B., Kamperman, A. M., Tol, W. A., Knipscheer, J. W., & Kleber, R. J. (2014). Seven-year follow-up study of symptoms in asylum seekers and refugees with PTSD treated with trauma-focused groups. Journal of Clinical Psychology, 70(4), 376–387.
Gone, J. P. (2013). Redressing first Nations historical trauma: Theorizing mechanisms for indigenous culture as mental health treatment. Transcultural Psychiatry, 50(5), 683–706.
Griner, D., & Smith, T. B. (2006). Culturally adapted mental health intervention: A meta-analytic review. Psychotherapy, 43(4), 531–548.
Haque, A. (2004). Religion and mental health: The case of American Muslims. Journal of Religion and Health, 43(1), 45–58.
Hinton, D. E. (2012). Multicultural challenges in the delivery of anxiety treatment. Depression and Anxiety, 29(1), 1–3.
Hinton, D. E. (2014). Assessment and treatment in non-Western countries. In P. Emmelkamp & E. Ehring (Eds.), The Wiley handbook of anxiety disorders (pp. 1268–1278). Hoboken, NJ: Wiley.
Hinton, D. E., Chhean, D., Pich, V., Safren, S. A., Hofmann, S. G., & Pollack, M. H. (2005). A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: A cross-over design. Journal of Traumatic Stress, 18(6), 617–629.
Hinton, D. E., & Good, B. J. (Eds.). (2009). Culture and panic disorder. Palo Alto, CA: Stanford University Press.
Hinton, D. E., & Good, B. J. (2016a). The culturally sensitive assessment of trauma: Eleven analytic perspectives, a typology of errors, and the multiplex models of distress generation. In D. E. Hinton & B. J. Good (Eds.), Culture and PTSD: Trauma in historical and global perspective (pp. 50–113). Philadelphia, PA: University of Pennsylvenia Press.
Hinton, D. E., & Good, B. J. (Eds.). (2016b). Culture and PTSD: Trauma in historical and global perspective. Philadelphia, PA: University of Pennsylvenia Press.
Hinton, D. E., & Hinton, A. L. (2015). An anthropology of the effects of genocide and mass violence: Memory, symptom, and recovery. In D. E. Hinton & A. L. Hinton (Eds.), Genocide and mass violence: Memory, symptom, and recovery (pp. 1–45). Cambridge: Cambridge University Press.
Hinton, D. E., Hinton, A. L., Eng, K.-T., & Choung, S. (2012). PTSD and key somatic complaints and cultural syndromes among rural Cambodians: The results of a needs assessment survey. Medical Anthropology Quarterly, 29, 147–154.
Hinton, D. E., Hofmann, S. G., Pitman, R. K., Pollack, M. H., & Barlow, D. H. (2008). The panic attack–PTSD model: Applicability to orthostatic panic among Cambodian refugee. Cognitive Behaviour Therapy, 37(2), 101–116.
Hinton, D. E., Hofmann, S. G., Pollack, M. H., & Otto, M. W. (2009). Mechanisms of efficacy of CBT for Cambodian refugees with PTSD: Improvement in emotion regulation and orthostatic blood pressure response. CNS Neuroscience and Therapeutics, 15(3), 255–263.
Hinton, D. E., Hofmann, S. G., Rivera, E., Otto, M. W., & Pollack, M. H. (2011). Culturally adapted CBT for Latino women with treatment-resistant PTSD: A pilot study comparing CA-CBT to Applied Muscle Relaxation. Behaviour Research and Therapy, 49(4), 275–280.
Hinton, D. E., & Kirmayer, L. J. (2013). Local responses to trauma: Symptom, affect, and healing. Transcultural Psychiatry, 50(5), 607–621.
Hinton, D. E., Kredlow, M. A., Pich, V., Bui, E., & Hofmann, S. G. (2013). The relationship of PTSD to key somatic complaints and cultural syndromes among Cambodian refugees attending a psychiatric clinic: The Cambodian Somatic Symptom and Syndrome Inventory (SSI). Transcultural Psychiatry, 50(3), 347–370.
Hinton, D. E., & Lewis-Fernández, R. (2010). Idioms of distress among trauma survivors: Subtypes and clinical utility. Culture, Medicine and Psychiatry, 34(2), 209–218.
Hinton, D. E., & Lewis-Fernández, R. (2011). The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression and Anxiety, 28(9), 783–801.
Hinton, D. E., Lewis-Fernández, R., Kirmayer, L. J., & Weiss, M. G. (2016). Supplementary module 1: Explanatory module. In R. Lewis-Fernandez, N. Aggarwal, L. Hinton, D. Hinton, & L. J. Kirmayer (Eds.), The DSM-5 handbook on the cultural formulation interview (pp. 53–67). Washinton, DC: American Psychiatric Press.
Hinton, D. E., Nickerson, A., & Bryant, R. A. (2011). Worry, worry attacks, and PTSD among Cambodian refugees: A path analysis investigation. Social Science and Medicine, 72(11), 1817–1825.
Hinton, D. E., Ojserkis, R., Jalal, B., Peou, S., & Hofmann, S. G. (2013). Loving kindness to treat traumatized refugees and minority groups: A typology of mindfulness and the Nodal Network Model (NNM) of affect and affect regulation. Journal of Clinical Psychology, 69(8), 817–828.
Hinton, D. E., Pham, T., Tran, M., Safren, S. A., Otto, M. W., & Pollack, M. H. (2004). CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: A pilot study. Journal of Traumatic Stress, 17(5), 429–433.
Hinton, D. E., Pich, V., Hofmann, S. G., & Otto, M. W. (2013). Mindfulness and acceptance techniques as applied to refugee and ethnic minority populations: Examples from culturally adapted CBT (CA-CBT). Cognitive and Behavioral Practice, 20(1), 33–46.
Hinton, D. E., Pich, V., Marques, L., Nickerson, A., & Pollack, M. H. (2010). Khyâl attacks: A key idiom of distress among traumatized Cambodian refugees. Culture, Medicine and Psychiatry, 34(2), 244–278.
Hinton, D. E., Reis, R., & de Jong, J. T. (2015). The “thinking a lot” idiom of distress and PTSD: An examination of their relationship among traumatized Cambodian refugees using the “Thinking a Lot” Questionnaire. Medical Anthropology Quarterly, 29(3), 357–380.
Hinton, D. E., Reis, R., & de Jong, J. T. (2016). A transcultural model of the centrality of “thinking a lot” in psychopathologies across the globe and the process of localization: A Cambodian refugee example. Culture, Medicine, and Psychiatry, 40(4), 570–619.
Hinton, D. E., Rivera, E., Hofmann, S. G., Barlow, D. H., & Otto, M. W. (2012). Adapting CBT for traumatized refugees and ethnic minority patients: Examples from culturally adapted CBT (CA-CBT). Transcultural Psychiatry, 49(2), 340–365.
Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69(4), 621–632.
Hwang, W. C. (2006). The psychotherapy adaptation and modification framework: Application to Asian Americans. American Psychologist, 61(7), 702–715.
Jordans, M. J., & Tol, W. A. (2013). Mental health in humanitarian settings: Shifting focus to care systems. International Health, 5(1), 9–10.
Kaiser, B., McLean, K., Kohrt, B. A., Hagaman, A., Wagenaar, B. H., Khoury, N. M., & Keys, H. M. (2014). Reflechi twòp–thinking too much: Description of a cultural syndrome in Haiti’s Central Plateau. Culture, Medicine, and Psychiatry, 38(3), 448–472.
Kleinman, A., & Good, B. J. (Eds.). (1985). Culture and depression: Studies in anthropology and cross-cultural psychiatry of affect and disorder. Berkeley, CA: University of California Press.
Lester, K., Resick, P. A., Young-Xu, Y., & Artz, C. (2010). Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment. Journal of Consulting and Clinical Psychology, 78(4), 480–489.
McNally, R. J. (2012). The ontology of posttraumatic stress disorder: Natural kind, social construction, or causal system? Clinical Psychology Science and Practice, 19(3), 220–228.
Mollica, R. F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., & Lavelle, J. (1992). The Harvard trauma questionnaire. Journal of Nervous and Mental Disease, 180(2), 111–116.
Morina, N., & Ford, J. (2008). Complex sequelae of psychological trauma among Kosovar civilian war victims. International Journal of Social Psychiatry, 54(5), 425–436.
Morkved, N., Hartmann, K., Aarsheim, L. M., Holen, D., Milde, A. M., Bomyea, J., & Thorp, S. R. (2014). A comparison of narrative exposure therapy and prolonged exposure therapy for PTSD. Clinical Psychology Review, 34(6), 453–467.
Morris, S. E., & Cuthbert, B. N. (2012). Research domain criteria: Cognitive systems, neural circuits, and dimensions of behavior. Dialogues in Clinical Neuroscience, 14(1), 29–37.
Murray, L. K., Dorsey, S., Haroz, E., Lee, E., Alsiary, M. M., Haydary, A., … Bolton, P. (2014). A common elements approach for adult mental health problems in low- and middle-income countries. Cogntive and Behavioral Practice, 21(2), 111–123.
Naeem, F., Waheed, W., Gobbi, M., Ayub, M., & Kingdon, D. (2011). Preliminary evaluation of culturally sensitive CBT for depression in Pakistan: Findings from Developing Culturally-Sensitive CBT Project (DCCP). Behavioural and Cognitive Psychotherapy, 39(2), 165–173.
Nezu, A. M., Nezu, C. M., & Lombardo, E. (2004). Cognitive-behavioral case formulation to treatment design a problem-solving approach. New York, NY: Springer.
Nickerson, A., Bryant, R. A., Silove, D., & Steel, Z. (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review, 31(3), 399–417.
Nickerson, A., & Hinton, D. E. (2011). Anger regulation in traumatized Cambodian refugees: The perspectives of Buddhist monks. Culture, Medicine, and Psychiatry, 35(3), 396–416.
Patel, V. (2012). Global mental health: From science to action. Harvard Review of Psychiatry, 20(1), 6–12.
Patel, V., Kirkwood, B. R., Pednekar, S., Weiss, H., & Mabey, D. (2006). Risk factors for common mental disorders in women. Population-based longitudinal study. British Journal of Psychiatry, 189(6), 547–555.
Patel, V., Simunyu, E., & Gwanzura, F. (1995). Kufungisisa (thinking too much): A Shona idiom for non-psychotic mental illness. Central African Journal of Medicine, 41(7), 209–215.
Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. JAMA, 294(5), 602–612.
Rutherford, B. R., & Roose, S. P. (2013). A model of placebo response in antidepressant clinical trials. American Journal of Psychiatry, 170(7), 723–733.
Tsai, M., Ogrodniczuk, J. S., Sochting, I., & Mirmiran, J. (2014). Forecasting success: Patients’ expectations for improvement and their relations to baseline, process and outcome variables in group cognitive-behavioural therapy for depression. Clinical Psycholology and Psychotherapy, 21(2), 97–107.
United Nations High Commissioner for Refugees. (2016). Global trends: Forced displacement in 2015. Geneva, Switzerland: Author.
van Ginneken, N., Tharyan, P., Lewin, S., Rao, G. N., Meera, S., Pian, J., et al. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Systemic Review, 11, CD009149.
Ventevogel, P., Jordans, M., Reis, R., & de Jong, J. (2013). Madness or sadness? Local concepts of mental illness in four conflict-affected African communities. Conflict and Health, 7(1), 3.
Yarris, K. E. (2014). “Pensando mucho” (“thinking too much”): Embodied distress among grandmothers in Nicaraguan transnational families. Culture, Medicine, and Psychiatry, 38(3), 473–498.
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Hinton, D.E., Patel, A. (2018). Culturally Sensitive CBT for Refugees: Key Dimensions. In: Morina, N., Nickerson, A. (eds) Mental Health of Refugee and Conflict-Affected Populations. Springer, Cham. https://doi.org/10.1007/978-3-319-97046-2_10
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