Culturally Sensitive Implementation of Cognitive Therapy in Treating Depression

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  • 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

    Journal of Multicultural SocialWorkPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wzmu20

    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.

    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

    To link to this article: http://dx.doi.org/10.1300/J285v04n02_06

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  • Culturally Sensitive Implementation of Cognitive Therapy in Treating Depression

    Judith L. Norman

    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..]

    INTRODUCTION

    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, & 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.

    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.

    Dr. Norman is Assistant Professor of Social Work, School of Social Work, Brigham Young University, Provo, UT 84602

    Journal of Multicultural Social Work, Vol. 4(2) 1996 0 1996 by The Haworth Press, Inc. All dghts reserved. 75

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  • 76 JOURNAL OF MUUK'ULTURAL SOCIAL, WORK

    LITERATURE REVXBW

    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, & Erbaugh, 1961; Jarrett & Rush, 1986; Morris, 1975; Murphy, Simons, Wetzel, & Lustman, 1984; National Institute of Mental Health, 1986; Rush, Beck, Kovacs, & Hollon, 1977; Schotte & Clum, 1987; Taylor & Marshall, 1977; Teasedale, Fen- nell, Hibbert, & Amies, 1983) and cognitive therapy combined with me- dication (Blackbum, Bishop, Glen, Whalley, & Christie, 1981; Jarrett, 1990; Rounsaville, Merman, & 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.

    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 & Greenberger, 1987; Aneshensel, Clark, & Frerichs, 1983; Golding, Kamo, & Rutter, 1990; Heinman & Good, 1985; Kroll, Habenicht, Mack- enzie, Yang, Chan, Vang, Nguyen, Ly, Phommasouvanh, Nguyen, Vmg, Souvannasoth, & Cabugoa, 1989; Rogler, 1989; Vega, Kolody, Valle, & Hough, 1986; Westemeyer, 1985).

    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.

    AN INTERACTIONAL MODEL OF ASSESSING AND TREATING DEPRESSION

    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

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  • Judith L. Norman 77

    FIGURE 1. Symptoms of unipolar affective disorders

    Poor appetite, weight loss

    Sleep disturbances

    Psychomotor agitation or retardation

    Decreased sexual drive

    Environmental (interpersonal) 0

    Loss of interest

    Social withdrawal

    Reduced ability to concentrate

    Indecisiveness

    Feelings of worthlessness, self- rep roach, guilt, helplessness, and hopelessness

    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.

    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.

    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

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  • 78 JOURNAL OF MULTICULTURAL SUCIAL WORK

    FIGURE 2. Interaction

    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.

    a person may be better prepared to receive the benefits of psychothempy, aimed at reduction of symptoms in the psychologic domain. Clearly, i