Guidelines for the implementation of culturally sensitive cognitive

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    Guidelines for the implementation of culturally sensitive CBTamong refugees and in global contextsIntervention 2014, Volume 12, Supplement 1, Page 78 - 93

    Guidelines for the implementation ofculturally sensitive cognitivebehavioural therapy among refugeesand in global contexts

    Devon E. Hinton & BalandJalal

    In this article, we suggest guidelines that should befollowed in order to create a culturally sensitive cog-nitive behavioural therapy among refugees and inglobal contexts moregenerally, so as to maximise e-cacy and eectiveness.These guidelines can be fol-lowed to design culturally sensitive cognitivebehavioural therapy studies, or what might be calledcontextually sensitive cognitive behavioural therapy,amongrefugeesorotherculturalgroups in agivenglo-bal location, and the guidelines can be used to evalu-ate such studies. Some examples of these guidelinesare culturally appropriate framing of cognitive beha-vioural therapy techniques, assessing and addressingkey local complaints (e.g. somatic symptoms, spiritpossession and syndromes such as thinking a lot)and catastrophic cognitions about those complaints,and incorporating into treatment key local sourcesof recovery and resilience.

    Keywords: cognitive behavioural therapy,global health, refugees

    IntroductionStudiesindicatethepotentialecacyofcogni-tive behavioural therapy (CBT) among refu-gees and in global contexts (e.g. Bass et al.,2013;Drozdek,Kamperman,Tol,Knipscheer,& Kleber, 2014; Murray et al., 2014). Thisarticle suggests ways to make the next waveofCBTtreatmentsamongrefugeesandwithingloballocationsmoresensitivetoculturalcon-text.Arecentarticleadvocatedthatachecklistbe used for all studies published in journals toassure their cultural sensitivity (Lewis-Fer-na ndez et al., 2013). Here we suggest a kind of

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    checklist that canbe used to evaluate the cul-tural sensitivity (or whatmight alsobe calledcontextual sensitivity)ofaCBTinterventionamong refugees or other cultural groups in agiven global location. Many of theseparameters have guided our treatment devel-opmentandtheglobalhealthresearchagendamore generally (Hinton, Chhean, Pich, Saf-ren, Hofmann, & Pollack 2005; Hinton, Hof-mann, Pollack, & Otto, 2009; Hinton,Hofmann, Rivera, Otto, & Pollack, 2011a;Hinton, Pham,Tran, Safren, Otto, & Pollack,2004; Hinton, Rivera, Hofmann, Barlow, &Otto, 2012b; Patel, 2012; van Ginneken et al.,2013).

    Guidelines for theimplementation of culturallysensitive CBTIn Figure 1, we give an overview of theparameters and a subgrouping of thoseparameters that should be assessed in deter-mining the cultural sensitivity of a treatment.

    Background informationIdentify the cultural group Identifyingthe exact cultural group is importantbecauseitwill inuencemanyoftheparametersbelow,such as a groups history of trauma, stigma inthe group about mental illness, catastrophiccognitions about symptoms and religiousbased techniques that may be included intreatment. Moreover, determining the exactcultural group that a study involves givesinsights into generalisability. Moreover, in

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    Identify the exact cultural group

    Specify language of group and oftreatment

    Identify key demographics variables(gender, socioeconomic, education,

    literacy) Making CBT techniques tolerable and credibleDetermine religious background

    Address typical traumas in the group

    Address key stressors of the group

    Describe how and where the patient was identified and recruited in the health care system

    Identify and address key DSM-5 disorders

    Create models of how disorder is generated in thegroup in question to identify treatment targets

    Identify and address complaints of most concern to the thosebeing treated (e.g., local illness categories)

    Identify and address complaints of mostconcern to the community

    Utilise local sources of resilience and recovery

    Make the treatment consonant with the localethnopsychology, ethnophysiology and ethnospirituality

    Utilise culturally appropriate metaphors and proverbs

    Address stigma about the disorder and getting treatment for the disorder

    Address structural barriers to treatment

    Attend to social demand and economic effects

    Increase credibility and positive expectancy

    Maximise adherence

    Specify scale-up and sustainability potential

    Dimensions ofCulturally Sensitive


    Identify and address key psychopathological dimensions(e.g., somatic sensation and catastrophic cognitions)

    Address mechanisms and dimensions of psychopathologyIdentify and address keylocal concerns

    Assess relevant background informationand impact on treatment

    Address key ecological factors Maximise access

    Issues of patienttherapist matching

    Maximise acceptablity and efficacy

    Include local illness categories asoutcome measures

    Figure 1: Key parameters for evaluating the degree of culturally sensitivity of a treatment.

    DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.


    outcome studies, it allows a determination ofthe cultural heterogeneity of a sample andmakes possible some balancing of treatmentarms. However, often treatment studiessimply state that the participants are from acertain country without discussing the cul-tural group or whether all or some of theparticipants are from aminority or an ethnicgroup.As anexample, LatinosmaybeCarib-bean Latino (e.g. from Puerto Rico or theDominican Republic), Central American,Peruvian,orMexican,amongotherlocalities,with each of these groups having dierentsocial and cultural histories, further, withinthose countries there are large minoritygroups(e.g.QuechuainPeru).Or, foranotherexample, many Burmese are members ofKaren or other hill tribe groups, groups thatare culturally distinct from the majority ofBurmese.Likewise,apersonidentiedasIraqicould belong to an Arabic, Kurdish,Turkme-nian or Assyrian cultural group, and couldbe Muslim (Sunni, Shia, Alevi),Yezidi, Zor-oastrian, Christian or Jewish, with each ofthese groups falling under the general

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    categoryof Iraqi, and in somecasesbelongingtothesamereligiousdenomination(e.g.SunniIslam), and may have very dierent culturalcustoms. For example, although Arabs andKurds are both Iraqis and Sunni Muslims,their cultural customs dier.Specify the language of the group andlanguage of treatmentThelanguagesthatthe participants speak should be speciedandwhether the treatment was conducted inthe preferred or a secondary language, andwhether a translator was used. Degree ofuency of the client in the language in whichtherapywas conducted needs tobe described.For example, in many countries, there aremultiple languages spoken but a singlenational language, with variable uency inthe national language. For example, in Iraq,whileArabicisthenationallanguage,inmajorparts of Northern Iraq Arabic is not spoken,but ratherKurdish andTurkman.Identify key demographic variables Inaddition to gender, the treatment populationshouldbe characterised intermsof keydemo-graphic variables such as socio-economic

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    Guidelines for the implementation of culturally sensitive CBTamong refugees and in global contextsIntervention 2014, Volume 12, Supplement 1, Page 78 - 93

    status (SES), educationand literacy level. It isimportant to know these variables so as toevaluate the generalisability of a particularintervention. For example, the level of edu-cation and literacy will determine whetherwritten handouts can be used. Similarly,DVDsmay notbewell accepted among somemembers of lower SESwho donot commonlyuse them. As an alternative to written hand-outs and DVDs, it may be necessary to draweasy-to-understand diagrams and gures.SES may indicate adherence to traditionalculture and religion, a measure of accultura-tion. In addition, variables such as SES mayindicate current levels of stress, which mayinuence the ability to tolerate and benetfrom therapy: exposure may be contraindi-cated (Lester, Resick, Young-Xu, & Artz,2010; see also the section below,Identify andaddress key stressors).Detail the religious background of thegroup and its impact on treatmentOne should characterise the group in ques-tion in respect to religious background. Isthe group mainly Buddhist, Christian, Mus-lim or another religion, and what is thedistribution in the group? Which type ofBuddhism (e.g.Theravandanor Zen), Chris-tianity (e.g. Pentecostal or Catholic) orIslam (e.g. Sunni or Shia)? Furthermore,the way religion is practised and the levelof religiosity may dier, even within thesame subbranch of a religion.Theway SunniIslam is practiced in Saudi Arabia (whereadherents often have a sala orientation ofIslam) may dier in some respects from theway Sunni Islam is practiced in, say, Egyptor Morocco; for instance, gender inter-actions outside marriage and ones immedi-ate family may be more restricted in theformer population. Religious hybridityshould also be taken into account: Christian-ity among the Sepedi tribe of South Africais an amalgamation of traditional Christian-ity and local beliefs in ancestral spirits, evilcurses and black magic.As is discussed in a section below, ideallylocal religious leaders should rst be

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    consulted to determine their understandingof the types of distress in the population,what religious and other treatments theythink should occur and how they thinkwestern type interventions might be success-fully conducted. Religious or spiritual beliefsmay provide sources of resilience or con-stitute obstacles to care. In some Islamiccultures, it may


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