History of Culturally Adapted Intervention
Culturally adapted therapies or culturally-centered therapies refer to the psychotherapeutic intervention which addresses the cultural characteristics of diverse clients, including his beliefs and value systems, attitudes and socio-economic and historical contexts (Sperry, 2009). It utilizes traditional healing methods and pathways, like the following: cuento therapy and morita therapy. The former addresses culturally relevant concepts such as familismo and personalismo with the use of folk tales (cuento) (Sperry, 2009). Meanwhile, the latter was originated from Japan and is now widely used throughout the world for various mental illnesses such as schizophrenia and shyness (Sperry, 2009).
The idea that culturally competent therapies must be accessible to the members of ethnic minority groups has been started in the last forty years. During these years, there has been heightened attention and concern regarding both the availability and quality of care given to ethnic minority clients who need mental health services (Orlandi, et. al., 1992). Ethnic minorities were also disillusioned with mental health services for various reasons, such as the lack of bilingual therapists and the existence of racial prejudices and stereotypes among some therapists (Orlandi, et. al., 1992). As an outcome, the mental health professionals have become more conscious of the significance of identifying cultural factors when treating culturally diverse populations (Orlandi, et. al., 1992).
According to Wendt & Gone (2011), the development of guidelines and standards for cultural competence in American psychology started after the American Civil Rights movement. Cultural competence soon emerged as a means to remedy the perceived irrelevance, alienation and even harm that might befall ethno-racially diverse clients seeking general treatment from Euro-American therapists (Wendt & Gone, 2011).
Description of Intervention
A culturally adapted therapy is a conventional Western intervention that has been modified to adapt to the cultural beliefs and ways of the clients. In this type of therapy, the therapist uses cultural interventions, such as a discussion with the client of his core cultural values in order to develop a positive relationship with the client (Sperry, 2009). This process establishes a sense of clinical credibility for the client. Then, the therapist proceeds to discuss the actual treatment for the client.
Culturally adapted therapies involve various features such as ethnic combination, language mix, adaptation of values/content, providing outside resources to support client well-being, among others (Chang, 2012). The very vital consideration, however, is that the modified treatment which fulfills the cultural background of the client. Hence, psychotherapy with clients of a certain racial/cultural background will differ vastly, according to the geographic region, urban/suburban location, socio-economic position, acculturation level, etc. of the said client (Chang, 2012).
According to Strasser, Chhim, & Taing (2012), it integrates western and local approaches to trauma healing. It also uses the testimonial method by combining traditional and religious practices. In the case of its practice in Cambodia, the integration of traditional and religious practices include the chanting of monks, blessing and purification rituals, the use of protective strings, among others. This is based on the importance of traditional coping mechanisms in Cambodia's spirit based culture. The worldview of individuals as determined by his culture influence their responses to misfortune, poverty, psychosocial misery and psychological disorder and has implications for interventions (Strasser, Chhim, & Taing, 2012).
In a culturally adapted NET approach, Cambodia’s Khmer Rouge victims are motivated to talk about their traumatic experiences. The therapist restores their painful memories and transforms them into a written testimony. This testimony is read out loud and sent to the survivors by monks from a local pagoda in a Buddhist customary ceremony along other survivors.
Summary of Empirical Evidence
The culturally adapted Net therapy showed a significant reduction in the posttraumatic symptoms and depression scores of Khmer Rouge victims (Strasser, Chhim, & Taing, 2012). The research findings demonstrated that producing and receiving a testimony which records traumatic experiences is an important part in promoting rehabilitation for human rights violations victims. The qualitative outcomes also show that coping with political violence is mainly linked to the cultural and societal constructions of meaning (Strasser, Chhim, & Taing, 2012). The persisting bonds to the ancestors aid the survivors to confront and make sense of their personal losses.
The significance of ancestor relationships helps explain people’s suffering who were never able to organize for the required rituals at the death of their relatives. The concept of “making merit” and the effect it may have on the afterlife as well as the certainty that no acts will remain without consequences, are vital concepts in understanding psychological issues and prospective solutions” (Strasser, Chhim, & Taing, 2012). By offering goods to the monks, the ritual is perceived as producing merits. These merits are delivered to the dead so as to ease their suffering and to make their future existence as good as possible. Since they believe that the dead are still linked with the living, the quality of these associations and the dynamics is important in perceiving and affecting the survivors’ mental state. This culturally adapted approach very well combines trauma exposure techniques with the encouragement of social acknowledgment and the combination of religious and traditional practices which generally resemble a prospective approach in addressing the different aspects of traumatization brought about by the political violence in Cambodia (Strasser, Chhim, & Taing, 2012).
In another study, Duarte-Velez, Bernal, & Bonilla (2010) showed how a culturally adapted cognitive-behavioral therapy (CBT) can promote loyalty to a treatment protocol while enabling for ample flexibility to address a client’s values, preferences, and context. A manual-based CBT was applied to a gay Latino adolescent on his sexual identity, family values, and spiritual perceptions. The adolescent suffered from a major depression disorder and considered himself as gay and Christian under a conservative and machista Puerto Rican family. This therapy enhanced personal acceptance and active interplay of homophobic thoughts in a spirit of family respect. The therapy allowed for identity formation and integration, central to the development of a sexual identity for lesbian, gay, bisexual, and transgender youth, with remission of the client’s depression and better family outcomes (Duarte-Velez, Bernal, & Bonilla, 2010).
In another study, Kohn, et. al. (2002), examined the level to which a manual cognitive behavioral therapy intervention can be adapted to be culturally sensitive in the treatment of depressed, low-income African American women with varied stressors. The cultural adaptations made to an existing intervention consisted of a group treatment developed for depressed low-income medical clients.
This treatment (CBT) is made up of three four-session cognitive behavioral modules. After the completion of each of the three modules, clients repeat the first module for 16 sessions in all. These modules hinge on activities, cognitions and relationships and were based on cognitive behavioral treatment for depression as detailed by Lewinsohn and colleagues and used for minority primary care clients by Muñoz (Kohn, et. al., 2002). In the CBT intervention, the clients are supplied with a manual with outlines of each session and weekly homework assignments.
New clients are introduced in on-going groups at the start of each four-week module. Kohn, et. al.’s culturally adapted treatment or AACBT is based on various changes to the current CBT intervention through several sources such as theoretical literatures, published details of treatment approaches applied to African American women, and consultation with therapists who have also treated African American women before. The adaptations are both structural and didactic. The latter refers to changes in the therapy’s structure and process while the latter pertains to the changes in the content of the material to be taken week by week (Kohn, et. al., 2002).
Structural adaptations consists of the following: 1.) reducing the group to African American women, of any age, with a prognosis of Major Depressive Disorder; 2.) closing the said group to promote cohesion, and 3.) supplementing experiential meditative exercises during the treatment and ending it with a ritual at the end of the 16-week intervention; and 4.) changes in some of the language used to define cognitive-behavioral techniques (Kohn, et. al., 2002).
The assessment of the adapted treatment in which outcomes of African American women treated in the culturally adapted group were studied against the African American women treated in the non-adapted group. After their respective treatments, the women in the culturally adapted group showed a larger drop in average BDI scores.
Culturally adapted therapies are effective and popular with ethnic clients yet there are only a selected few therapists who are good in practicing this in the United States (Sperry, 2009). It has also been remarked that this therapy less effective with more highly acculturated individuals as they may not resonate with the traditional healing practices incorporated into the culturally adapted therapies. Thus, it only works better with clients of lower acculturation levels (Sperry, 2009).
Another form of limitation mentioned in the literature is the narrow perspective associated with this therapy. While it is common to assume that there are differences in certain demographic groups, there are many ways in which both therapists and their clients could be “different” (Sperry, 2009). This is due in part to the truth that some aspects of difference are not instantly apparent. It is also attributed to the fact that it is the individual’s sense of their difference which matters. On this ground, almost any therapeutic dynamics needs the therapist to take into account the issue of difference.
According to Chang (2012), the areas influenced by culture in the therapist/client relationship are the direction of future research. One of the most significant elements of effective psychotherapy is the relationship between the client and therapist. Studies show that therapists impact account for about 6 to 9 percent of variance in treatment outcomes (Chang, 2012). It is also stressed that the selection of the clients’ therapeutic approaches hinges on multiculturalism. Hence, clients from ethnic minorities would benefit from seeking therapists who are multi-culturally competent.
The reason for culturally adapted therapies remains strong and is more extensively accepted than before. From mere acceptance of the principles behind the practice of culturally adapted therapies, it has evolved into a widespread application and subsequent assessment is founded on various empirical evidences. Based on this study, it can be inferred that:
- Clients will tend to take advantage of the psychotherapists’ attempt to align treatment with their clients’ cultural backgrounds. This was especially true for Asian American and adult clients, who tended to take advantage of culturally adapted treatments as compared to clients of other racial groups and other demographics.
- Since both age and ethnic American cultures tend to be linked to acculturation status, therapists must perceive well how client age and acculturation relate with their treatments.
- In the future, psychotherapy will be more likely be conducted in the client’s chosen language.
- Culturally adapted treatments must address varied components. The more adapted to clients’ cultural backgrounds, the greater the effectiveness of the therapy. The more culturally customized the treatment, the more effective it will probably show.
Chang, E. C. & Downey, C. A. (2012). C. A. Downey (eds.), Handbook of Race and Development in Mental Health. Michigan State University, M.I.
Duarte-Velez, Y., Bernal, G. & Bonilla, K. (2010). Culturally adapted cognitive-behavior therapy: integrating sexual, spiritual, and family identities in an evidence-based treatment of a depressed Latino adolescent. Journal of Clinical Psychology, 66(8), p. 895-906.
Kohn, L., Oden, T., Muñoz, R., Robinson, A., & Leavitt, D. (2002). Brief Report: Adapted Cognitive Behavioral Group Therapy for Depressed Low Income African American Women. Community Mental Health Journal, Vol. 38 (6).
Orlandi, M. A., et. al. (1992). Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working with Ethnic/Racial Communities. CSAP Cultural Competencies Series. Rockville, M.D.: U.S. Department of Health and human Services.
Sperry, Len. (2009). Highly Effective Therapy: Developing Essential Clinical Competencies in Counseling and Psychotherapy. London: Routledge.
Smith, Timothy, Rodriguez, Melanie D., & Bernal, Guillermo. (2010). Culture. New York: Oxford University Press.
Strasser, J., Chhim, Dr. S., & Taing, S. (2012). Narrative Exposure Therapy (NET): Culturally Sensitive Trauma Treatment for Khmer Rouge Survivors. Retrieved on October 7, 2013 from, http://www.undv.org/vesak2012/iabudoc/09StrasserFINAL.pdf.
Wendt, D. C. & Gone, J. (2011). Rethinking Cultural Competence: Insights from Indigenous Community Treatment Settings. Transcultural Psychiatry, 49 (2), p. 206- 222.