Advertisement

Culturally Sensitive CBT for Refugees: Key Dimensions

  • Devon E. Hinton
  • Anushka Patel
Chapter

Abstract

In increasingly multicultural societies, cognitive behavioral therapy (CBT) needs to be made appropriate for diverse groups. Refugees with mental health difficulties present particular therapeutic challenges that include complex trauma, different cultural traditions, and ongoing stress. The current chapter outlines how a contextually sensitive CBT can be developed for such refugee groups. It outlines key dimensions of culturally sensitive CBT, which can be therapeutically implemented among refugees in order to maximize efficacy and effectiveness. These guidelines can be followed to design culturally sensitive CBT studies among refugees, or what might be called “contextually sensitive CBT,” and the guidelines can be used to evaluate such studies. Some examples of these key dimensions of care are the following: assessing and addressing key local complaints (e.g., somatic symptoms, spirit possession, and syndromes like “thinking a lot”); incorporating into treatment key local sources of recovery and resilience (e.g., CBT-compatible proverbs and techniques in that culture). Another example of a key dimension of care is making CBT techniques more tolerable and effective for the cultural group through various means: by using a phased approach, by utilizing culturally appropriate framing of CBT techniques (using local analogies), by making positive re-associations to problematic sensations during interoceptive exposure (e.g., to traditional games), and by using trauma-type exposure as an opportunity to practice emotion regulation. We describe such concepts as explanatory model bridging, cultural grounding, and contextual sensitivity.

Keywords

Culture CBT Trauma Refugees 

References

  1. Agger, I., Igreja, V., Kiehle, R., & Polatin, P. (2012). Testimony ceremonies in Asia: Integrating spirituality in testimonial therapy for torture survivors in India, Sri Lanka, Cambodia, and the Philippines. Transcultural Psychiatry, 49(3–4), 568–589.PubMedPubMedCentralGoogle Scholar
  2. Amer, M., & Jalal, B. (2011). Individual psychotherapy/counseling: Psychodynamic, cognitive behavioral and humanistic-experiential models. In S. Ahmed & M. Amer (Eds.), Counseling Muslims: Handbook of mental health issues and interventions (pp. 87–117). New York, NY: Routledge.Google Scholar
  3. Bass, J. K., Annan, J., McIvor Murray, S., Kaysen, D., Griffiths, S., Cetinoglu, T., … Bolton, P. A. (2013). Controlled trial of psychotherapy for Congolese survivors of sexual violence. New England Journal of Medicine, 368(23), 2182–2191.PubMedGoogle Scholar
  4. Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology, 58(3), 279–289.PubMedGoogle Scholar
  5. Bernal, G., Jiménez-Chafey, M. I., & Domenech Rodríguez, M. D. (2009). Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40(4), 361–368.Google Scholar
  6. Bolton, P., Michalopoulos, L., Ahmed, A. M., Murray, L. K., & Bass, J. (2013). The mental health and psychosocial problems of survivors of torture and genocide in Kurdistan, Northern Iraq: A brief qualitative study. Torture, 23(1), 1–14.PubMedGoogle Scholar
  7. Bolton, P., Surkan, P. J., Gray, A. E., & Desmousseaux, M. (2012). The mental health and psychosocial effects of organized violence: A qualitative study in northern Haiti. Transcultural Psychiatry, 49(3–4), 590–612.PubMedGoogle Scholar
  8. Casey, B. J., Craddock, N., Cuthbert, B. N., Hyman, S. E., Lee, F. S., & Ressler, K. J. (2013). DSM-5 and RDoC: Progress in psychiatry research? Nature Reviews: Neuroscience, 14(11), 810–814.PubMedGoogle Scholar
  9. Chisholm, D., Flisher, A. J., Lund, C., Patel, V., Saxena, S., Thornicroft, G., & Tomlinson, M. (2007). Scale up services for mental disorders: A call for action. The Lancet, 370(9594), 1241–1252.Google Scholar
  10. Crumlish, N., & O’Rourke, K. (2010). A systematic review of treatments for post-traumatic stress disorder among refugees and asylum-seekers. Journal of Nervous and Mental Disease, 198(4), 237–251.PubMedGoogle Scholar
  11. de Jong, J. T., Komproe, I. H., Spinazzola, J., van der Kolk, B. S., & van Ommeren, M. H. (2005). DESNOS in three postconflict settings: Assessing cross-cultural construct equivalence. Journal of Traumatic Stress, 18(1), 13–21.PubMedGoogle Scholar
  12. de Jong, J. T., & Reis, R. (2010). Kiyang-yang, a West-African postwar idiom of distress. Culture, Medicine, and Psychiatry, 34(2), 301–321.Google Scholar
  13. de Jong, J. T., & Reis, R. (2013). Collective trauma resolution: Dissociation as a way of processing post-war traumatic stress in Guinea Bissau. Transcultural Psychiatry, 50(5), 644–661.PubMedGoogle Scholar
  14. Drozdek, B., Kamperman, A. M., Tol, W. A., Knipscheer, J. W., & Kleber, R. J. (2014). Seven-year follow-up study of symptoms in asylum seekers and refugees with PTSD treated with trauma-focused groups. Journal of Clinical Psychology, 70(4), 376–387.PubMedGoogle Scholar
  15. Gone, J. P. (2013). Redressing first Nations historical trauma: Theorizing mechanisms for indigenous culture as mental health treatment. Transcultural Psychiatry, 50(5), 683–706.PubMedGoogle Scholar
  16. Griner, D., & Smith, T. B. (2006). Culturally adapted mental health intervention: A meta-analytic review. Psychotherapy, 43(4), 531–548.PubMedGoogle Scholar
  17. Haque, A. (2004). Religion and mental health: The case of American Muslims. Journal of Religion and Health, 43(1), 45–58.Google Scholar
  18. Hinton, D. E. (2012). Multicultural challenges in the delivery of anxiety treatment. Depression and Anxiety, 29(1), 1–3.PubMedGoogle Scholar
  19. Hinton, D. E. (2014). Assessment and treatment in non-Western countries. In P. Emmelkamp & E. Ehring (Eds.), The Wiley handbook of anxiety disorders (pp. 1268–1278). Hoboken, NJ: Wiley.Google Scholar
  20. Hinton, D. E., Chhean, D., Pich, V., Safren, S. A., Hofmann, S. G., & Pollack, M. H. (2005). A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: A cross-over design. Journal of Traumatic Stress, 18(6), 617–629.PubMedPubMedCentralGoogle Scholar
  21. Hinton, D. E., & Good, B. J. (Eds.). (2009). Culture and panic disorder. Palo Alto, CA: Stanford University Press.Google Scholar
  22. Hinton, D. E., & Good, B. J. (2016a). The culturally sensitive assessment of trauma: Eleven analytic perspectives, a typology of errors, and the multiplex models of distress generation. In D. E. Hinton & B. J. Good (Eds.), Culture and PTSD: Trauma in historical and global perspective (pp. 50–113). Philadelphia, PA: University of Pennsylvenia Press.Google Scholar
  23. Hinton, D. E., & Good, B. J. (Eds.). (2016b). Culture and PTSD: Trauma in historical and global perspective. Philadelphia, PA: University of Pennsylvenia Press.Google Scholar
  24. Hinton, D. E., & Hinton, A. L. (2015). An anthropology of the effects of genocide and mass violence: Memory, symptom, and recovery. In D. E. Hinton & A. L. Hinton (Eds.), Genocide and mass violence: Memory, symptom, and recovery (pp. 1–45). Cambridge: Cambridge University Press.Google Scholar
  25. Hinton, D. E., Hinton, A. L., Eng, K.-T., & Choung, S. (2012). PTSD and key somatic complaints and cultural syndromes among rural Cambodians: The results of a needs assessment survey. Medical Anthropology Quarterly, 29, 147–154.Google Scholar
  26. Hinton, D. E., Hofmann, S. G., Pitman, R. K., Pollack, M. H., & Barlow, D. H. (2008). The panic attack–PTSD model: Applicability to orthostatic panic among Cambodian refugee. Cognitive Behaviour Therapy, 37(2), 101–116.PubMedPubMedCentralGoogle Scholar
  27. Hinton, D. E., Hofmann, S. G., Pollack, M. H., & Otto, M. W. (2009). Mechanisms of efficacy of CBT for Cambodian refugees with PTSD: Improvement in emotion regulation and orthostatic blood pressure response. CNS Neuroscience and Therapeutics, 15(3), 255–263.PubMedPubMedCentralGoogle Scholar
  28. Hinton, D. E., Hofmann, S. G., Rivera, E., Otto, M. W., & Pollack, M. H. (2011). Culturally adapted CBT for Latino women with treatment-resistant PTSD: A pilot study comparing CA-CBT to Applied Muscle Relaxation. Behaviour Research and Therapy, 49(4), 275–280.PubMedPubMedCentralGoogle Scholar
  29. Hinton, D. E., & Kirmayer, L. J. (2013). Local responses to trauma: Symptom, affect, and healing. Transcultural Psychiatry, 50(5), 607–621.PubMedGoogle Scholar
  30. Hinton, D. E., Kredlow, M. A., Pich, V., Bui, E., & Hofmann, S. G. (2013). The relationship of PTSD to key somatic complaints and cultural syndromes among Cambodian refugees attending a psychiatric clinic: The Cambodian Somatic Symptom and Syndrome Inventory (SSI). Transcultural Psychiatry, 50(3), 347–370.PubMedGoogle Scholar
  31. Hinton, D. E., & Lewis-Fernández, R. (2010). Idioms of distress among trauma survivors: Subtypes and clinical utility. Culture, Medicine and Psychiatry, 34(2), 209–218.PubMedGoogle Scholar
  32. Hinton, D. E., & Lewis-Fernández, R. (2011). The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression and Anxiety, 28(9), 783–801.PubMedGoogle Scholar
  33. Hinton, D. E., Lewis-Fernández, R., Kirmayer, L. J., & Weiss, M. G. (2016). Supplementary module 1: Explanatory module. In R. Lewis-Fernandez, N. Aggarwal, L. Hinton, D. Hinton, & L. J. Kirmayer (Eds.), The DSM-5 handbook on the cultural formulation interview (pp. 53–67). Washinton, DC: American Psychiatric Press.Google Scholar
  34. Hinton, D. E., Nickerson, A., & Bryant, R. A. (2011). Worry, worry attacks, and PTSD among Cambodian refugees: A path analysis investigation. Social Science and Medicine, 72(11), 1817–1825.PubMedGoogle Scholar
  35. Hinton, D. E., Ojserkis, R., Jalal, B., Peou, S., & Hofmann, S. G. (2013). Loving kindness to treat traumatized refugees and minority groups: A typology of mindfulness and the Nodal Network Model (NNM) of affect and affect regulation. Journal of Clinical Psychology, 69(8), 817–828.PubMedGoogle Scholar
  36. Hinton, D. E., Pham, T., Tran, M., Safren, S. A., Otto, M. W., & Pollack, M. H. (2004). CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: A pilot study. Journal of Traumatic Stress, 17(5), 429–433.PubMedPubMedCentralGoogle Scholar
  37. Hinton, D. E., Pich, V., Hofmann, S. G., & Otto, M. W. (2013). Mindfulness and acceptance techniques as applied to refugee and ethnic minority populations: Examples from culturally adapted CBT (CA-CBT). Cognitive and Behavioral Practice, 20(1), 33–46.Google Scholar
  38. Hinton, D. E., Pich, V., Marques, L., Nickerson, A., & Pollack, M. H. (2010). Khyâl attacks: A key idiom of distress among traumatized Cambodian refugees. Culture, Medicine and Psychiatry, 34(2), 244–278.PubMedPubMedCentralGoogle Scholar
  39. Hinton, D. E., Reis, R., & de Jong, J. T. (2015). The “thinking a lot” idiom of distress and PTSD: An examination of their relationship among traumatized Cambodian refugees using the “Thinking a Lot” Questionnaire. Medical Anthropology Quarterly, 29(3), 357–380.PubMedGoogle Scholar
  40. Hinton, D. E., Reis, R., & de Jong, J. T. (2016). A transcultural model of the centrality of “thinking a lot” in psychopathologies across the globe and the process of localization: A Cambodian refugee example. Culture, Medicine, and Psychiatry, 40(4), 570–619.Google Scholar
  41. Hinton, D. E., Rivera, E., Hofmann, S. G., Barlow, D. H., & Otto, M. W. (2012). Adapting CBT for traumatized refugees and ethnic minority patients: Examples from culturally adapted CBT (CA-CBT). Transcultural Psychiatry, 49(2), 340–365.PubMedPubMedCentralGoogle Scholar
  42. Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69(4), 621–632.PubMedGoogle Scholar
  43. Hwang, W. C. (2006). The psychotherapy adaptation and modification framework: Application to Asian Americans. American Psychologist, 61(7), 702–715.PubMedGoogle Scholar
  44. Jordans, M. J., & Tol, W. A. (2013). Mental health in humanitarian settings: Shifting focus to care systems. International Health, 5(1), 9–10.PubMedGoogle Scholar
  45. Kaiser, B., McLean, K., Kohrt, B. A., Hagaman, A., Wagenaar, B. H., Khoury, N. M., & Keys, H. M. (2014). Reflechi twòp–thinking too much: Description of a cultural syndrome in Haiti’s Central Plateau. Culture, Medicine, and Psychiatry, 38(3), 448–472.Google Scholar
  46. Kleinman, A., & Good, B. J. (Eds.). (1985). Culture and depression: Studies in anthropology and cross-cultural psychiatry of affect and disorder. Berkeley, CA: University of California Press.Google Scholar
  47. Lester, K., Resick, P. A., Young-Xu, Y., & Artz, C. (2010). Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment. Journal of Consulting and Clinical Psychology, 78(4), 480–489.PubMedGoogle Scholar
  48. McNally, R. J. (2012). The ontology of posttraumatic stress disorder: Natural kind, social construction, or causal system? Clinical Psychology Science and Practice, 19(3), 220–228.Google Scholar
  49. Mollica, R. F., Caspi-Yavin, Y., Bollini, P., Truong, T., Tor, S., & Lavelle, J. (1992). The Harvard trauma questionnaire. Journal of Nervous and Mental Disease, 180(2), 111–116.PubMedGoogle Scholar
  50. Morina, N., & Ford, J. (2008). Complex sequelae of psychological trauma among Kosovar civilian war victims. International Journal of Social Psychiatry, 54(5), 425–436.PubMedGoogle Scholar
  51. Morkved, N., Hartmann, K., Aarsheim, L. M., Holen, D., Milde, A. M., Bomyea, J., & Thorp, S. R. (2014). A comparison of narrative exposure therapy and prolonged exposure therapy for PTSD. Clinical Psychology Review, 34(6), 453–467.PubMedGoogle Scholar
  52. Morris, S. E., & Cuthbert, B. N. (2012). Research domain criteria: Cognitive systems, neural circuits, and dimensions of behavior. Dialogues in Clinical Neuroscience, 14(1), 29–37.PubMedPubMedCentralGoogle Scholar
  53. Murray, L. K., Dorsey, S., Haroz, E., Lee, E., Alsiary, M. M., Haydary, A., … Bolton, P. (2014). A common elements approach for adult mental health problems in low- and middle-income countries. Cogntive and Behavioral Practice, 21(2), 111–123.Google Scholar
  54. Naeem, F., Waheed, W., Gobbi, M., Ayub, M., & Kingdon, D. (2011). Preliminary evaluation of culturally sensitive CBT for depression in Pakistan: Findings from Developing Culturally-Sensitive CBT Project (DCCP). Behavioural and Cognitive Psychotherapy, 39(2), 165–173.PubMedGoogle Scholar
  55. Nezu, A. M., Nezu, C. M., & Lombardo, E. (2004). Cognitive-behavioral case formulation to treatment design a problem-solving approach. New York, NY: Springer.Google Scholar
  56. Nickerson, A., Bryant, R. A., Silove, D., & Steel, Z. (2011). A critical review of psychological treatments of posttraumatic stress disorder in refugees. Clinical Psychology Review, 31(3), 399–417.PubMedPubMedCentralGoogle Scholar
  57. Nickerson, A., & Hinton, D. E. (2011). Anger regulation in traumatized Cambodian refugees: The perspectives of Buddhist monks. Culture, Medicine, and Psychiatry, 35(3), 396–416.Google Scholar
  58. Patel, V. (2012). Global mental health: From science to action. Harvard Review of Psychiatry, 20(1), 6–12.PubMedPubMedCentralGoogle Scholar
  59. Patel, V., Kirkwood, B. R., Pednekar, S., Weiss, H., & Mabey, D. (2006). Risk factors for common mental disorders in women. Population-based longitudinal study. British Journal of Psychiatry, 189(6), 547–555.PubMedGoogle Scholar
  60. Patel, V., Simunyu, E., & Gwanzura, F. (1995). Kufungisisa (thinking too much): A Shona idiom for non-psychotic mental illness. Central African Journal of Medicine, 41(7), 209–215.PubMedGoogle Scholar
  61. Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. JAMA, 294(5), 602–612.PubMedGoogle Scholar
  62. Rutherford, B. R., & Roose, S. P. (2013). A model of placebo response in antidepressant clinical trials. American Journal of Psychiatry, 170(7), 723–733.PubMedGoogle Scholar
  63. Tsai, M., Ogrodniczuk, J. S., Sochting, I., & Mirmiran, J. (2014). Forecasting success: Patients’ expectations for improvement and their relations to baseline, process and outcome variables in group cognitive-behavioural therapy for depression. Clinical Psycholology and Psychotherapy, 21(2), 97–107.Google Scholar
  64. United Nations High Commissioner for Refugees. (2016). Global trends: Forced displacement in 2015. Geneva, Switzerland: Author.Google Scholar
  65. van Ginneken, N., Tharyan, P., Lewin, S., Rao, G. N., Meera, S., Pian, J., et al. (2013). Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Systemic Review, 11, CD009149.Google Scholar
  66. Ventevogel, P., Jordans, M., Reis, R., & de Jong, J. (2013). Madness or sadness? Local concepts of mental illness in four conflict-affected African communities. Conflict and Health, 7(1), 3.PubMedPubMedCentralGoogle Scholar
  67. Yarris, K. E. (2014). “Pensando mucho” (“thinking too much”): Embodied distress among grandmothers in Nicaraguan transnational families. Culture, Medicine, and Psychiatry, 38(3), 473–498.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Harvard UniversityBostonUSA
  2. 2.Department of PsychologyUniversity of TulsaTulsaUSA

Personalised recommendations