Parameters for Creating Culturally Sensitive CBT: Implementing CBT in Global Settings

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    Parameters for Creating Culturally SeSe

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    cultural sensitivity of a CBT intervention in a global context.These parameters have guided our treatment development

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    Identify the Cultural Group

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    ScienceDCognitive and Behavioral PractChristian, or Jewish. This is important because it will havean impact on many of the parameters below, such as a

    Keywords: global health; CBT; culture; implementation; scale up;assessment; transdiagnostic treatment; culture; treatment adapta-et al., 2013) that show thepotential efficacy of CBT in globalcontexts, this commentary suggests ways to make the nextwave of CBT treatments in global contexts sensitive tocultural context. A recent article advocated for a checklist tobe used for all studies published in journals to assure their

    The particular cultural groups ideally should beidentified. For example, many Burmese are Karen andother hill tribe members, a culturally separate group fromthe majority of Burmese. Often identity is nestedforexample, a Tamil speaker in Hindi-speaking India. Or aperson identified as Iraqi could belong to an Arabic,Kurdish, Turkmenian, or Assyrian cultural group, andtion;

    1077 20Publents Treatment Approach (CETA), and they state itbe given by lay counselors. It is a modular treatment.he authors indicate, several research groups haveloped transdiagnostic protocols (e.g., Barlow et al.,; Norton, 2008). The researchers describe theirion of transdiagnostic CBT and discuss how trainingconducted and some aspects of the treatment. In thispilot study, the treatment seemed feasible and well

    and the global health research agenda more gener(Hinton et al., 2005; Hinton, Hofmann, Pollack, & O2009; Hinton, Hofmann, Rivera, Otto, & Pollack, 20Hinton et al., 2004; Hinton, Rivera, Hofmann, BarlowOtto, 2012; La Roche, 2012; Patel, 2012; van Ginneket al., 2013).

    Parameters to Evaluate the Cultural Sensitivity oCBT Intervention in Global ContextsElem allyGlobal

    Devon E. Hinton, Massachusetts General Hospital andBaland Jalal

    The current article is a commentary on the article, A CommonMiddle-Income Countries, which describes a form of transdiaBurmese and Iraqi group. Murray et al.s (this issue) article iscontexts. In this commentary, we suggest a set of parameters to crefficacy and effectiveness. When applicable, we will discuss waysstudy. These parameters can be used more generally to design custudies. Some examples of these parameters are culturally appropcomplaints (e.g., somatic symptoms) and local catastrophic cogn

    M URRAY et al.s (2014this issue) study suggests thatthe transdiagnostic CBT they have developed maybe effective as implemented in low- and middle-incomecountries. They refer to the treatment as a Commonglobal health; PTSD

    -7229/12/139-144$1.00/014 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.tary

    nsitive CBT: Implementing CBT inttings

    rvard Medical School and Arbour Counseling ServicesSan Diego

    ents Approach for Adult Mental Health Problems in Low- andic CBT and its implementation among a highly traumatizedof several new studies indicating the efficacy of CBT in globalulturally sensitive CBT in global settings in a way to maximizeich these parameters are illustrated by Murray et al. in this pilotly sensitive CBT studies in global contexts and to evaluate suchframing of CBT techniques, assessing and addressing key local, and incorporating key local sources of recovery and resilience.

    cultural sensitivity (Lewis-Fernndez et al., 2013). Here wesuggest a kind of checklist that could be used to evaluate the

    irectice 21 (2014) 139-144 history of trauma, stigma in the group aboutmental illness, catastrophic cognitions about symptoms,and religious-based techniques that may be included intreatment.

  • 140 Hinton & JalalSpecify the Language of the Group and Languageof Treatment

    It is important to indicate the languages the partici-pants speak and whether the treatment was conducted inthe preferred or a secondary language. For example, inmany countries there are multiple languages spoken but asingle national language, with variable fluency in thenational language: in Iraq, while Arabic is the nationallanguage, in major parts of Northern Iraq Arabic is notspoken, but rather Kurdish and Turkman. Degree offluency of the client in the language in which therapy wasconducted needs to be described. Developing treatmentstailored to the specific regional culture and regionallinguistic dialects is essential to enhance client engage-ment and communicate lessons in terms of daily lifeexperiences.

    Identify Key Demographic Variables

    The treatment population should be characterized interms of key demographic variables such as economicstatus, education, and literacy level. For example, the levelof education and literacy will affect the ability to givewritten handouts. It is also important to know thesevariables so as to evaluate generalizability of a particularintervention.

    Detail the Religious Background of the Group

    One should characterize the group in question inrespect to religious background. Is the group mainlyBuddhist, Christian, Muslim, or another religion, and whatis the distribution in the group? Which type of Buddhism(e.g., Theravandan or Zen), Christianity (e.g., Pentecostalor Catholic), or Islam (e.g., Shia or Sunni)? Whenconducting a treatment, religious or spiritual beliefsmay provide sources of resilience or particular obstaclesto care. The local religion may provide ways to frametreatment to make it more acceptable. For example,Murray et al. (2014this issue) made sure to matchtherapist and client in respect to gender at the Iraqi siteto adapt treatment to religious beliefs.

    Identify Typical Traumas in the Group

    It is crucially important to identify the traumas that agroup being treated typically experiences. It may be thatthe group in question endured mass violence of somekind, may be fleeing from a genocide or civil war, andmayhave high rates of sexual violence. When providingeducation about CBT, these traumas can be specificallydescribed and addressed. Identifying traumas is alsocrucially important from a public health standpoint: itmay be found that sexual violence or domestic violenceis endemic in a certain context. This has importantimplications in respect to treatment and public healthinterventions: the therapist should be careful to specifi-cally query about a history of the trauma such as domesticviolence, should be sensitized to its possible presence, andshould be aware of what local resources are available forsomeone so impacted.

    Identify and Address Key Stressors

    It has been shown that worry may be a key generator ofdistress in traumatized populations and other populations(Hinton & Lewis-Fernndez, 2011; Hinton, Nickerson, &Bryant, 2011). From a public health standpoint, whenapplying CBT in global contexts, it is important to beaware of local problems that may be addressed for theentire group: security concerns, refugee status, access towater, and so on (Hinton & Good, in press). Ideally thestressors may be addressed at the community level as animportant public health intervention. Also, one shouldspecify whether the participant sees someone who canhelp address key practical problems, such as theequivalent of a social worker. The CBT may need toaddress practical problems as part of treatment, a kind ofbehavioral activation and didactics in coping (Nezu,Nezu, & Lombardo, 2004).

    Describe How and Where the Patient Was Identifiedand Recruited in the Health Care System

    It is critically important to specify how patients wererecruited, such as from community samples, a primarycare setting, or other locations. This gives insight into thenature of the health care system and gives informationabout the generalizability to other contexts.

    Identify Key DSM Disorders

    In certain groups like traumatized refugees, one of thegroups in this study, certain disorders like PTSD andpanic disorder may be particularly elevated (Hinton &Lewis-Fernndez, 2011). Each group may have a uniqueprofile of DSM disorders; for example, among Cambodi-an refugees, other than PTSD, there are extremely highrates of panic attacks and panic disorder. The profile ofdisorder will inform treatment and the design andimplementation of modules. For example, if PTSD iscommon in a locality, then this should influenceassessment and the usually given modules. Murray et al.(2014this issue) indicate that in the Iraqi group all hadPTSD and depression, while in the Burmese group, 68%PTSD, 37.5% depression.

    Identify Key Psychopathological Dimensions

    Other than DSM disorders, it is important to identifykey psychopathological dimensions in a group, such as

  • 141Commentary: Parameters for Creating Culturally Sensitive CBTpathological worry (rather than GAD), catastrophiccognitions, or panic attacks (Hinton, Nickerson, et al.,2011; Morris & Cuthbert, 2012). This is in keeping withthe call for dimensional analysis and impacts on themodules that will be provided in treatment.

    Identify the Exact Somatic Complaints of Concern

    It has been found that somatic symptoms are promi-nent in many non-Western populations (Hinton & Good,2009; Hinton & Lewis-Fernndez, 2011). Ideally oneshould identify key somatic concerns in a population sothat these may be addressed in CBT. This can beconsidered as the assessment of a psychopathologicaldimension, namely, somatic complaints, but with the aimof assessing key somatic complaints, in order to avoid anabstraction error, meaning only considering somaticsymptoms in general without assessing key symptoms ofconcern. Not assessing key somatic symptoms is also anexample of category truncation (Hinton & Good, inpress; Hinton & Lewis-Fernndez) in respect to assessinglocal distress, and so too is not assessing other keyconcerns such as catastrophic cognitions.

    Create Models of How Disorder Is Generated in thePopulation in Question to Identify Treatment Targets

    For a population, the way that particular complaintscome to be generated should be identified. We have donethis to explain the high rates of somatic complaints andpanic attacks among Cambodian refugees, showing, forexample, triggers of somatic arousal such as worry orstanding up from the sitting or lying position and the keyrole of catastrophic cognitions about and trauma associ-ations to those sensations (Hinton & Good, 2009; Hinton,Hofmann, Pitman, Pollack, & Barlow, 2008; Hinton,Nickerson, et al., 2011; Hinton, Pich, Marques, Nickerson,& Pollack, 2010).

    Identify and Address Key Catastrophic Cognitions

    A standard part of CBT is addressing catastrophiccognitions about symptoms such as about PTSD symp-toms and somatic symptoms (Hinton & Good, in press;Hinton, Rivera, et al., 2012). For example, manyCambodian refugees fear that neck soreness indicatesthat the neck vessels will burst, and they fear that dizzinesson standing indicates the onset of a dangerous khylattack, or wind attack, a surge of khyl and blood upwardin the body that may cause various disasters (Hinton et al.,2010). Or many Cambodians think that worry willoverheat the brain and cause permanent forgetfulness.Learning the local ethnopsychology, ethnophysiology,and ethnospirituality as it applies to symptoms andprocesses like worry is a key way of identifying thesecatastrophic cognitions. In every culture, there will belocal ideas about how symptoms of anxiety and depressionare generated and treated. More generally, we havesuggested that all outcome studies in cross-culturalsettings should include a list of locally salient somaticcomplaints, catastrophic cognitions, and cultural syn-dromes not assessed in standard measures, what we havecalled Symptom and Syndrome Inventories, for exam-ple, a Cambodian Symptom and Syndrome Inventory,or C-SSI (Hinton, Hinton, Eng, & Choung, 2012; Hinton,Kredlow, Pich, Bui, & Hofmann, 2013).

    Making CBT Techniques Tolerable and Credible for theCultural Group

    Exposure for trauma may be particularly problematic.It has been found that conducting exposure amongethnic populations presents challenges and may lead todropout and worsening (Hinton, 2012). Even withWestern populations, in treatments conducted by adoctoral-level therapist, this approach has been consid-ered problematic (Hinton, 2012). A phase approach hasbeen suggested, among other methods, to increaseexposure tolerability. Murray et al. (2014this issue)employ analogies to make exposure more tolerable:configuring imaginal exposure as cleaning a wound. InIraq, using a more culturally specific metaphor, theauthors framed exposure in a way that creates positiveexpectancy: the fear women have of making bread on anopen fire, a fear that diminishes over time. The authorsalso mentioned metaphors that were used that are notculturally specific but rather grounded in daily life tomake treatment more acceptable: configuring learningthe cognitive triangle as a spoonful of treatment, owingto the local popularity of taking medication for ills.

    Identify Issues of TherapistClient Matching

    In particular, this is important in respect to gender. Asthe authors describe, in the Iraqi context the therapistshould be of the same gender.

    Identify and Address Complaints of Most Concern toThose Being Treated

    In a cultural context, certain symptoms will be of greatconcern: among many Cambodian refugees, sleep paral-ysis, dizziness, poor sleep, and panic attacks (Hinton et al.,2013). Of note, the key local complaints may be culturalsyndromes. For example, Cambodians frequently attri-bute anxiety symptoms to heart weakness and windattacks (khyl attacks), and these attributions producemultiple catastrophic cognitions. As described below,framing treatment as addressing these key complaintsgreatly increases CBT acceptability and adherence. Asdescribed above, failure to assess and treat key concerns

  • Increase Credibility and Positive Expectancy

    treatment as incorporating local therapeutic techniques

    used certain metaphors to increase positive expectancy

    142 Hinton & Jalalsuch as somatic symptoms and cultural syndromes wouldbe a case of category truncation.

    Identify and Address Complaints of Most Concern tothe Community

    One should ask local leaders about which behavioraland symptomatic issues are of key concern, askingspecifically about violence, substance abuse, and suicid-ality in the community. If the treatment is then framed asaddressing these issues, it will reduce stigma about theailment and mobilize the community.

    Utilize Local Sources of Resilience and Recovery

    In certain localities, there may be healing traditionssuch as Buddhist meditation or Sufism that are helpful topatients (Hinton & Kirmayer, 2013). These techniquescan inform the CBT treatment itself and its components,and participants m...


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