Culturally Sensitive Implementation of Cognitive Therapy in Treating Depression

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<ul><li><p>This article was downloaded by: [Arizona State University]On: 24 October 2014, At: 11:35Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK</p><p>Journal of Multicultural SocialWorkPublication details, including instructions forauthors and subscription information:</p><p>Culturally SensitiveImplementation of CognitiveTherapy in Treating DepressionJudith L. Norman aa School of Social Work , Brigham Young University ,Provo, UT, 84602, USAPublished online: 22 Oct 2008.</p><p>To cite this article: Judith L. Norman (1996) Culturally Sensitive Implementation ofCognitive Therapy in Treating Depression, Journal of Multicultural Social Work, 4:2,75-88, DOI: 10.1300/J285v04n02_06</p><p>To link to this article:</p><p>PLEASE SCROLL DOWN FOR ARTICLE</p><p>Taylor &amp; Francis makes every effort to ensure the accuracy of all theinformation (the Content) contained in the publications on our platform.However, Taylor &amp; Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness,or suitability for any purpose of the Content. Any opinions and viewsexpressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor &amp; Francis. The accuracy of theContent should not be relied upon and should be independently verified withprimary sources of information. Taylor and Francis shall not be liable for anylosses, actions, claims, proceedings, demands, costs, expenses, damages,and other liabilities whatsoever or howsoever caused arising directly orindirectly in connection with, in relation to or arising out of the use of theContent.</p><p></p></li><li><p>This article may be used for research, teaching, and private study purposes.Any substantial or systematic reproduction, redistribution, reselling, loan,sub-licensing, systematic supply, or distribution in any form to anyone isexpressly forbidden. Terms &amp; Conditions of access and use can be found at</p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>Ari</p><p>zona</p><p> Sta</p><p>te U</p><p>nive</p><p>rsity</p><p>] at</p><p> 11:</p><p>35 2</p><p>4 O</p><p>ctob</p><p>er 2</p><p>014 </p><p></p></li><li><p>Culturally Sensitive Implementation of Cognitive Therapy in Treating Depression </p><p>Judith L. Norman </p><p>ABSTRACT. Cognitive therapy a l m and in Combination with media- tions has p v e n to be an effective intervention when treating unipolar depression. An iilkxmo . nal model of assessing depression and cognitive process variables can elicit and spedy culturally relevant symptoms, ~ S X S , soufces, and outcome variables. [Articfe mpies avuiluble fmm T h Haworlh Document Deliveq Service: 180-342-9678..] </p><p>INTRODUCTION </p><p>Though there are things we do not know about depression, especially cross-culturally, we do know it is complex, multifaceted, and potentially lethal. Unipolar depressions, primarily Major Depression (Diugnosric and Sfufistical Manual of Mental Disorders-Revised [DSM m-R]), affect mil- lions of Americans yearly. In addition, 50-8096 of depressed clients will experience a recurrence at some time in their lives (Frank, Kupfer, &amp; Percel, 1989). Many sufferers do not seek professional assistance. Yet, much repeated research attests to the effective treatment of unipolar de- pressions. Recent literature addresses the significant reduction of symp- toms across several dimensions of depression utilizing combination thera- pies, specifically psychotherapy in conjunction with pharmacotherapy. </p><p>Among those psychotherapies found to be efficacious in treating Major Depression alone and in combination with medications, is cognitive thera- py. While little research has been completed to suggest the effectiveness of cognitive therapy across cultures, the process variables would seem to be conducive to culturally sensitive implementation, as will be explored in this paper. </p><p>Dr. Norman is Assistant Professor of Social Work, School of Social Work, Brigham Young University, Provo, UT 84602 </p><p>Journal of Multicultural Social Work, Vol. 4(2) 1996 0 1996 by The Haworth Press, Inc. All dghts reserved. 75 </p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>Ari</p><p>zona</p><p> Sta</p><p>te U</p><p>nive</p><p>rsity</p><p>] at</p><p> 11:</p><p>35 2</p><p>4 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>76 JOURNAL OF MUUK'ULTURAL SOCIAL, WORK </p><p>LITERATURE REVXBW </p><p>For the treatment of unipolar depression, a variety of diverse interven- tions have been examined including antidepressant medications, cognitive therapy alone (Beck, Ward, Mendolson, Mock, &amp; Erbaugh, 1961; Jarrett &amp; Rush, 1986; Morris, 1975; Murphy, Simons, Wetzel, &amp; Lustman, 1984; National Institute of Mental Health, 1986; Rush, Beck, Kovacs, &amp; Hollon, 1977; Schotte &amp; Clum, 1987; Taylor &amp; Marshall, 1977; Teasedale, Fen- nell, Hibbert, &amp; Amies, 1983) and cognitive therapy combined with me- dication (Blackbum, Bishop, Glen, Whalley, &amp; Christie, 1981; Jarrett, 1990; Rounsaville, Merman, &amp; Weissman, 1981; Rush, 1988). The Na- tional Institute of Mental Health (1986) suggested the need for further studies to assess the benefit of a combination treatment with depressed patients. </p><p>While literature repeatedly reports effective means of alleviating depressive symptoms, there are fewer studies that address variation in symptomology across cultures and limited studies that discuss the effec- tiveness of psychotherapies among diverse cultural populations. The liter- ature has explored the comparative data among Mexican Americans, Asian Refugees, Native Americans, and others in the United States (Ald- win &amp; Greenberger, 1987; Aneshensel, Clark, &amp; Frerichs, 1983; Golding, Kamo, &amp; Rutter, 1990; Heinman &amp; Good, 1985; Kroll, Habenicht, Mack- enzie, Yang, Chan, Vang, Nguyen, Ly, Phommasouvanh, Nguyen, Vmg, Souvannasoth, &amp; Cabugoa, 1989; Rogler, 1989; Vega, Kolody, Valle, &amp; Hough, 1986; Westemeyer, 1985). </p><p>Certainly, some symptoms and sources of depression will vary from culture to culture and the special features and dynamics of cultural minori- ties deserve unique and immediate attention. For example, racism may be considered a cause or source of depression (Fernando, 1983). However, some depressive symptoms are common across cultures and specific inter- ventions (e.g., cognitive therapy) may reduce particular symptoms. Such treatment strategies ought to be conducive to modifications effecting p i - tive change with diverse cultural populations. </p><p>AN INTERACTIONAL MODEL OF ASSESSING AND TREATING DEPRESSION </p><p>Unipolar depression is a multifaceted, multidimensional set of features and symptoms. Symptomatically, depression features criteria (DSM III-R) in at least three dimensions (see Figure 1). The specificity of symptoms </p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>Ari</p><p>zona</p><p> Sta</p><p>te U</p><p>nive</p><p>rsity</p><p>] at</p><p> 11:</p><p>35 2</p><p>4 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>Judith L. Norman 77 </p><p>FIGURE 1. Symptoms of unipolar affective disorders </p><p>Poor appetite, weight loss </p><p>Sleep disturbances </p><p>Psychomotor agitation or retardation </p><p>Decreased sexual drive </p><p>Environmental (interpersonal) 0 </p><p>Loss of interest </p><p>Social withdrawal </p><p>Reduced ability to concentrate </p><p>Indecisiveness </p><p>Feelings of worthlessness, self- rep roach, guilt, helplessness, and hopelessness </p><p>per country or culture may vary somewhat and there may be additional sympcoms in one or more areas. These symptoms constitute the most common or frequently occurring in the depressed patient. Also, signifi- cantly, the sources of these symptoms may vary greatly across cultures, especially with respect to cultural minorities. </p><p>In a patient expeiencing Major Depression, each domain may be more or less burdened with symptoms. However, symptoms in any of the three domains impact and compound symptoms in the other domains (see Fig- ure 2). For example, disturbances in sleep and energy (biology) may tend to foster or exaggerate diffhlties in concentration as well as initability and/or mood changes (psychology). Any or all of these symptoms, in turn, may negatively impact interpersonal relationships or job performance (en- vironment). Similarly, marital difficulties, constant poverty, or racial dis- crimination (environment) may contribute to mood fluctuations and/or initability @sychology), symptoms which may then lead to sleeping or eating changes and loss of energy. </p><p>Treaoment in the biologic domain, e.g., medications, seeks stabilization of physical symptoms. When sleeping and eating patterns are improved, mood may be positively affected. With these individual improvements, interpersonal or other environmental activities may likewise improve W o r </p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>Ari</p><p>zona</p><p> Sta</p><p>te U</p><p>nive</p><p>rsity</p><p>] at</p><p> 11:</p><p>35 2</p><p>4 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>78 JOURNAL OF MULTICULTURAL SUCIAL WORK </p><p>FIGURE 2. Interaction </p><p>W. From Awamess, Recagnha and Teatment (Un i i hy d Utah Graduate sdwd of Sodal Work and Federal DHHS Grant No. STC-9 1 TlSMH Sessol) by National lnsbiMe of Mental Health, 1987, Washington, DC: U.S. Gown- ment Prhting Office. </p><p>a person may be better prepared to receive the benefits of psychothempy, aimed at reduction of symptoms in the psychologic domain. Clearly, inter- ventim in any domain that produce positive results will have some impact on other domains, yet it cannot be assumed that intervention in one domain is sufficient to alleviate most symptoms in other domains. "Is, a combma- tion of medications and psychotherapies offer the most effective treamnt for unipolar depression in its variations and complexities. When there exist symptoms in any of the three domains, cliicians and </p><p>clinical educators must consider and plan for treatment strategies in each domain. Current, traditional interventions are noted in Figure 3. These strategies may need enlarging to more effectively treat culturally diverse populations. </p><p>Cognitive therapy has been identified as a psychotherapeutic interven- tion found to be effective in the treatment of depression (either alone or in combination with medications). Cognitive therapy specifically targets the psychological features and functioning of the depressed individual. Cogni- tive therapy does not purport to duectly alleviate biologic symptoms though it can arrest some symptom of depression and may augment symptom reduction brought about by antidepressants. Depressed persons are observed to operate from negative schema, often </p><p>interpreting views of self, others, and the future in negative terms (Beck, 1976; Meichenbaum, 1977). Cognitive theory suggests that such negative beliefs are learned. In the case of minority cultural experiences, lhis learning </p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>Ari</p><p>zona</p><p> Sta</p><p>te U</p><p>nive</p><p>rsity</p><p>] at</p><p> 11:</p><p>35 2</p><p>4 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>Judith L. Norman 79 </p><p>FIGURE 3. Interactional treatment model </p><p>Environmental Psychological 00 Medications </p><p>Nutrition </p><p>Exercise (recreation) </p><p>Relaxation training </p><p>Interpersonal Cognitive skills group therapy </p><p>Recreation Relaxation therapy training (via </p><p>guided imagery) </p><p>Note. From Depressbn: Awareness, R m M m , and Trearmnt (University of Utah Graduate school of Sodal Work and Federal DHHS Grant No. STC-9 1 T15MH 8889-01) by National Institute of Mental Health, 1987, Washington, DC: US. Government Printing office. </p><p>may have surpassed generations and may be maintained by social, political, even legal policies, programs, and behavior on the part of the larger culture. </p><p>Rehuning to the Interactional Model of assessment and treatment pre- viously described, it would be a mistake to simply evaluate the impact of culture as an environmental phenomenon. Cultural assessments must be utilized across the three domains (biology, psychology, environment) to more effectively identify a proper perspective of the role of cultural impact on an individual (see Figure 4). </p><p>Psychologically, racism (discrimination, prejudice) would likely foster poor self-esteem, possibly increase learned helplessness, and otherwise diminish healthy psychological functioning. Diverse cultural nams may also impede and thwart traditional means of offering psychotherapeutic intervention. Language barriers, poverty, transportation dioticuities, unfa- miliar avenues of resources, diverse spiritual beliefs, and other differences within minority groups may not lend themselves to the common structure of qutpatient psychiatric services. </p><p>Such issues (and many more) need to be examined as part of the assess- ment process. As one major component of the cognitive therapy process </p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>Ari</p><p>zona</p><p> Sta</p><p>te U</p><p>nive</p><p>rsity</p><p>] at</p><p> 11:</p><p>35 2</p><p>4 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>80 JOURNAL OF MULTICULTURAL SOCIAL WORK </p><p>FIGURE 4. Beginning cultural assessment </p><p>-View of body </p><p>-View of medications </p><p>-Consults with medicine men/ women, etc. </p><p>-Gender </p><p>-Family -Prejudice, constellation discrimination </p><p>-Socioeconomics Spiritual beliefs, (e.g., poverty) cognitive schema </p><p>-Institutional -Education racism, sexism, variables etc. </p><p>-Other -Other </p><p>-Other </p><p>variables, education of the client (about depression, for example) be- comes an education of the therapist as well, prior to proceeding on to the other pmess variables. The process variables of cognitive therapy include the following: educate patients about depression; share common experi- ences about depression; self-monitor, self-talk and examine underlying personal beliefs; pleasant activities, checklist activities; interpersonal skills training, problem-solving, relaxation training; and medication man- agement. </p><p>EDUCATION ABOUT DEPRESSION </p><p>In educating clients about depression, cultural issues must be raised when that client is from a different, especially minority, culture. While the identified criteria of unipolar depressions (DSM III-R) can be identified and shared wilh the client across biological, psychological, and envhn- </p><p>Dow</p><p>nloa</p><p>ded </p><p>by [</p><p>Ari</p><p>zona</p><p> Sta</p><p>te U</p><p>nive</p><p>rsity</p><p>] at</p><p> 11:</p><p>35 2</p><p>4 O</p><p>ctob</p><p>er 2</p><p>014 </p></li><li><p>Judith L. Norman 81 </p><p>mental dimensions, potential variations of symptoms and sowes of de- pression must be acknowledged as pertaining to a specific culture. Lan- guage may become a necessary variable to explore when educating culturally diverse populations. </p><p>In an analysis of eight different cultures (Australia, Indonesia, Japan, Korea, Malaysia, Puerto Rim, Sri Lanka, and the United States), Brandt and Boucher (1986) noted variable concepts regarding depressed feelings with some groups falling into a sadness cluster and others expanding depressed clusters to include shame, doubt, distrust, hate feelings. Of the eight cultures, fairly distinct clusters of depressive wording emerged despite cultural and linguistic differences. These authors suggested that the samples did not view depression as an either-or phenomena, rather the folk conceptions of depression reflected the loss (not absence) of positive and affirming feelings. Certainly, education of clients about depression would include a broad range and variability of language des- criptors to assist culturally diverse populations with an opportunity to reco...</p></li></ul>