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Cross-Cultural Considerations

Cognitive-behavioral interventions have been used with clients from a variety of cultural and ethnic backgrounds, especially in the past decade. As understanding about the needs of diverse clients develops, adaptations of standardized CBT treatments have been developed and studied. Cultural adaptations are essential because failure to consider the role of culture may alienate persons who are already disadvantaged and stigmatized. A sample of the research on how CBT can be used with people from diverse backgrounds follows.

The process for adapting a CBT group therapy to meet the unique needs of Haitian American adolescents (Nicolas, Amtz, Hirsch, & Schmiedigen, 2009) included creating an advisory board, partnering with the community, training focus group leaders to conduct specialized focus groups with Haitian adolescents, and using the information to make adaptations to an accepted treatment program for adolescent depression. Issues such as how depression looks in Haitian adolescents, what may be perceived as causing the depression, and treatment strategies that are acceptable were discussed in the focus groups. Many steps of review and adaptation were used to adapt an empirically supported treatment to the needs of this group.

When a cognitive-behavioral group treatment was specially adapted for a group of depressed low-income African American women (Kohn, Oden, Munoz, Robinson, & Leavitt, 2002), depression scores dropped significantly. In this pilot study, the scores for women in the adapted group dropped by 32 points, whereas scores in a standard CBT program dropped by 23 points. Additional research should be done to study these cultural adaptations. In this study, the changes to a standard CBT group treatment for depression included both structural and didactic adaptations. Structural issues were addressed, such as limiting the group to African American women, running the group closed to new members, and adding experiential meditative exercises and a termination ritual. In addition, some changes in terminology, such as therapeutic exercises instead of homework, were made. Also, when possible, anecdotes from African American literature were used to illustrate cognitive- behavioral concepts. Didactic changes, such as the addition of culturally specific sections of content, were also made to the standardized CBT program. For example, a section on African American family issues was added to focus on intergenerational patterns of behavior and reinforce the concept of families' history of strength. Family genograms were used and discussed in this section of the intervention.

Several articles focused on the applications of CBT to individuals from a Chinese background (Chan et al., 2005; Chen & Davenport, 2005; Lin, 2002; Molassiotis et al., 2002). Because the population of China is the largest in the world, it seems important to focus on this ethnic group. Authors reviewed assumptions that Western therapy approaches may be inappropriate for working with Asian populations and asserted that CBT is a viable treatment approach, with modifications for cultural considerations. Chen and Davenport (2005) highlighted the changes that could make the application of CBT work with Chinese Americans. For example, they noted that Socratic questioning may be less appropriate with Chinese American clients because they may feel ashamed or incompetent if they do not have the "right" answer. Instead, they recommended that counselors avoid asking too many personal questions in the beginning of the therapeutic process and use sentence starters such as "If I let my parents down ..." rather than "What thoughts come up for you when you think about letting your parents down?" (Chen & Davenport, 2005, p. 106).

Two applications of CBT approaches with Chinese patients who have symptomatic HIV have been published. Both studies reported that psychological distress is reduced and quality of life is enhanced by weekly sessions of CBT (Chan et al., 2005; Molassiotis et al., 2002).

Chinese clients may expect a more directive counselor, because Chinese clients have a tendency to seek information and advice, as well as direct ways to solve problems (Lin, 2002). Therapists or counselors using CBT may be able to connect with these needs by using problem-solving strategies and solution-focused approaches. However, other cultural issues such as the influence of the family may not fit as well with the internal locus of control and individual focus found in Western culture. It is clear that counselors who want to use CBT with Chinese clients are advised to read about Chinese culture and seek appropriate supervision (Lin, 2002).

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