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Culturally SensitiveImplementation of CognitiveTherapy in Treating DepressionJudith L. Norman aa School of Social Work , Brigham Young University ,Provo, UT, 84602, USAPublished online: 22 Oct 2008.

To cite this article: Judith L. Norman (1996) Culturally Sensitive Implementation ofCognitive Therapy in Treating Depression, Journal of Multicultural Social Work, 4:2,75-88, DOI: 10.1300/J285v04n02_06

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Culturally Sensitive Implementation of Cognitive Therapy in Treating Depression

Judith L. Norman

ABSTRACT. Cognitive therapy a l m and in Combination with media- tions has p v e n to be an effective intervention when treating unipolar depression. An iilkxmo . nal model of assessing depression and cognitive process variables can elicit and spedy culturally relevant symptoms, ~ S X S , soufces, and outcome variables. [Articfe mpies avuiluble fmm T h Haworlh Document Deliveq Service: 180-342-9678..]

INTRODUCTION

Though there are things we do not know about depression, especially cross-culturally, we do know it is complex, multifaceted, and potentially lethal. Unipolar depressions, primarily Major Depression (Diugnosric and Sfufistical Manual of Mental Disorders-Revised [DSM m-R]), affect mil- lions of Americans yearly. In addition, 50-8096 of depressed clients will experience a recurrence at some time in their lives (Frank, Kupfer, & Percel, 1989). Many sufferers do not seek professional assistance. Yet, much repeated research attests to the effective treatment of unipolar de- pressions. Recent literature addresses the significant reduction of symp- toms across several dimensions of depression utilizing combination thera- pies, specifically psychotherapy in conjunction with pharmacotherapy.

Among those psychotherapies found to be efficacious in treating Major Depression alone and in combination with medications, is cognitive thera- py. While little research has been completed to suggest the effectiveness of cognitive therapy across cultures, the process variables would seem to be conducive to culturally sensitive implementation, as will be explored in this paper.

Dr. Norman is Assistant Professor of Social Work, School of Social Work, Brigham Young University, Provo, UT 84602

Journal of Multicultural Social Work, Vol. 4(2) 1996 0 1996 by The Haworth Press, Inc. All dghts reserved. 75

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LITERATURE REVXBW

For the treatment of unipolar depression, a variety of diverse interven- tions have been examined including antidepressant medications, cognitive therapy alone (Beck, Ward, Mendolson, Mock, & Erbaugh, 1961; Jarrett & Rush, 1986; Morris, 1975; Murphy, Simons, Wetzel, & Lustman, 1984; National Institute of Mental Health, 1986; Rush, Beck, Kovacs, & Hollon, 1977; Schotte & Clum, 1987; Taylor & Marshall, 1977; Teasedale, Fen- nell, Hibbert, & Amies, 1983) and cognitive therapy combined with me- dication (Blackbum, Bishop, Glen, Whalley, & Christie, 1981; Jarrett, 1990; Rounsaville, Merman, & Weissman, 1981; Rush, 1988). The Na- tional Institute of Mental Health (1986) suggested the need for further studies to assess the benefit of a combination treatment with depressed patients.

While literature repeatedly reports effective means of alleviating depressive symptoms, there are fewer studies that address variation in symptomology across cultures and limited studies that discuss the effec- tiveness of psychotherapies among diverse cultural populations. The liter- ature has explored the comparative data among Mexican Americans, Asian Refugees, Native Americans, and others in the United States (Ald- win & Greenberger, 1987; Aneshensel, Clark, & Frerichs, 1983; Golding, Kamo, & Rutter, 1990; Heinman & Good, 1985; Kroll, Habenicht, Mack- enzie, Yang, Chan, Vang, Nguyen, Ly, Phommasouvanh, Nguyen, Vmg, Souvannasoth, & Cabugoa, 1989; Rogler, 1989; Vega, Kolody, Valle, & Hough, 1986; Westemeyer, 1985).

Certainly, some symptoms and sources of depression will vary from culture to culture and the special features and dynamics of cultural minori- ties deserve unique and immediate attention. For example, racism may be considered a cause or source of depression (Fernando, 1983). However, some depressive symptoms are common across cultures and specific inter- ventions (e.g., cognitive therapy) may reduce particular symptoms. Such treatment strategies ought to be conducive to modifications effecting p i - tive change with diverse cultural populations.

AN INTERACTIONAL MODEL OF ASSESSING AND TREATING DEPRESSION

Unipolar depression is a multifaceted, multidimensional set of features and symptoms. Symptomatically, depression features criteria (DSM III-R) in at least three dimensions (see Figure 1). The specificity of symptoms

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Judith L. Norman 77

FIGURE 1. Symptoms of unipolar affective disorders

Poor appetite, weight loss

Sleep disturbances

Psychomotor agitation or retardation

Decreased sexual drive

Environmental (interpersonal) 0

Loss of interest

Social withdrawal

Reduced ability to concentrate

Indecisiveness

Feelings of worthlessness, self- rep roach, guilt, helplessness, and hopelessness

per country or culture may vary somewhat and there may be additional sympcoms in one or more areas. These symptoms constitute the most common or frequently occurring in the depressed patient. Also, signifi- cantly, the sources of these symptoms may vary greatly across cultures, especially with respect to cultural minorities.

In a patient expeiencing Major Depression, each domain may be more or less burdened with symptoms. However, symptoms in any of the three domains impact and compound symptoms in the other domains (see Fig- ure 2). For example, disturbances in sleep and energy (biology) may tend to foster or exaggerate diffhlties in concentration as well as initability and/or mood changes (psychology). Any or all of these symptoms, in turn, may negatively impact interpersonal relationships or job performance (en- vironment). Similarly, marital difficulties, constant poverty, or racial dis- crimination (environment) may contribute to mood fluctuations and/or initability @sychology), symptoms which may then lead to sleeping or eating changes and loss of energy.

Treaoment in the biologic domain, e.g., medications, seeks stabilization of physical symptoms. When sleeping and eating patterns are improved, mood may be positively affected. With these individual improvements, interpersonal or other environmental activities may likewise improve W o r

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78 JOURNAL OF MULTICULTURAL SUCIAL WORK

FIGURE 2. Interaction

W. From Awamess, Recagnha and Teatment (Un i i hy d Utah Graduate sdwd of Sodal Work and Federal DHHS Grant No. STC-9 1 TlSMH Sessol) by National lnsbiMe of Mental Health, 1987, Washington, DC: U.S. Gown- ment Prhting Office.

a person may be better prepared to receive the benefits of psychothempy, aimed at reduction of symptoms in the psychologic domain. Clearly, inter- ventim in any domain that produce positive results will have some impact on other domains, yet it cannot be assumed that intervention in one domain is sufficient to alleviate most symptoms in other domains. "Is, a combma- tion of medications and psychotherapies offer the most effective treamnt for unipolar depression in its variations and complexities. When there exist symptoms in any of the three domains, cliicians and

clinical educators must consider and plan for treatment strategies in each domain. Current, traditional interventions are noted in Figure 3. These strategies may need enlarging to more effectively treat culturally diverse populations.

Cognitive therapy has been identified as a psychotherapeutic interven- tion found to be effective in the treatment of depression (either alone or in combination with medications). Cognitive therapy specifically targets the psychological features and functioning of the depressed individual. Cogni- tive therapy does not purport to duectly alleviate biologic symptoms though it can arrest some symptom of depression and may augment symptom reduction brought about by antidepressants. Depressed persons are observed to operate from negative schema, often

interpreting views of self, others, and the future in negative terms (Beck, 1976; Meichenbaum, 1977). Cognitive theory suggests that such negative beliefs are learned. In the case of minority cultural experiences, lhis learning

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Judith L. Norman 79

FIGURE 3. Interactional treatment model

Environmental Psychological 00 Medications

Nutrition

Exercise (recreation)

Relaxation training

Interpersonal Cognitive skills group therapy

Recreation Relaxation therapy training (via

guided imagery)

Note. From Depressbn: Awareness, R m M m , and Trearmnt (University of Utah Graduate school of Sodal Work and Federal DHHS Grant No. STC-9 1 T15MH 8889-01) by National Institute of Mental Health, 1987, Washington, DC: US. Government Printing office.

may have surpassed generations and may be maintained by social, political, even legal policies, programs, and behavior on the part of the larger culture.

Rehuning to the Interactional Model of assessment and treatment pre- viously described, it would be a mistake to simply evaluate the impact of culture as an environmental phenomenon. Cultural assessments must be utilized across the three domains (biology, psychology, environment) to more effectively identify a proper perspective of the role of cultural impact on an individual (see Figure 4).

Psychologically, racism (discrimination, prejudice) would likely foster poor self-esteem, possibly increase learned helplessness, and otherwise diminish healthy psychological functioning. Diverse cultural nams may also impede and thwart traditional means of offering psychotherapeutic intervention. Language barriers, poverty, transportation dioticuities, unfa- miliar avenues of resources, diverse spiritual beliefs, and other differences within minority groups may not lend themselves to the common structure of qutpatient psychiatric services.

Such issues (and many more) need to be examined as part of the assess- ment process. As one major component of the cognitive therapy process

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80 JOURNAL OF MULTICULTURAL SOCIAL WORK

FIGURE 4. Beginning cultural assessment

-View of body

-View of medications

-Consults with medicine men/ women, etc.

-Gender

-Family -Prejudice, constellation discrimination

-Socioeconomics Spiritual beliefs, (e.g., poverty) cognitive schema

-Institutional -Education racism, sexism, variables etc.

-Other -Other

-Other

variables, “education” of the client (about depression, for example) be- comes an education of the therapist as well, prior to proceeding on to the other pmess variables. The process variables of cognitive therapy include the following: educate patients about depression; share common experi- ences about depression; self-monitor, self-talk and examine underlying personal beliefs; pleasant activities, checklist activities; interpersonal skills training, problem-solving, relaxation training; and medication man- agement.

EDUCATION ABOUT DEPRESSION

In educating clients about depression, cultural issues must be raised when that client is from a different, especially minority, culture. While the identified criteria of unipolar depressions (DSM III-R) can be identified and shared wilh the client across biological, psychological, and envhn-

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Judith L. Norman 81

mental dimensions, potential variations of symptoms and sowes of de- pression must be acknowledged as pertaining to a specific culture. Lan- guage may become a necessary variable to explore when educating culturally diverse populations.

In an analysis of eight different cultures (Australia, Indonesia, Japan, Korea, Malaysia, Puerto Rim, Sri Lanka, and the United States), Brandt and Boucher (1986) noted variable concepts regarding depressed feelings with some groups falling into a “sadness” cluster and others expanding depressed clusters to include “shame, doubt, distrust, hate” feelings. Of the eight cultures, fairly distinct clusters of depressive wording emerged despite cultural and linguistic differences. These authors suggested that the samples did not view depression as an either-or phenomena, rather the “folk” conceptions of depression reflected “the loss (not absence) of positive and affirming feelings.” Certainly, education of clients about depression would include a broad range and variability of language des- criptors to assist culturally diverse populations with an opportunity to recognize the symptoms, scope, and complexity of this illness.

Education of culturally diverse clientele also must include references to social and political experiences that may cause or augment depressive symptoms. Environmental factors need not be restricted to the immediate interpersonal environment, but the larger society as well. Thus, discrimi- nation may be expressed in a specific relationship or the effects of institu- tional racism may impact heavily on an individual client. Aside from racism, other social factors must be considered. The effects of poverty u p individual and personal functioning must be evaluated in helping clients be less self-blaming and more socially aware of potential differen- tial treatment that may add to depressive symptomology and lowered self-esteem, feelings of lack (or loss) of control, feelings of helplessness or hopelessness, etc.

SHARE COMMON EXPERIENCES ABOUT DEPRESSION

When the education of culturally diverse persons regarding depression is broad and complete, noting symptoms in all three domains, the client can be encouraged to tell theii own “story” regarding depressive feelings, soufces of deplessive symptoms and various details. This is a second process vari- able of a cognitive therapy approach. ‘Ihere will usually be some common experiences given the onset of a clinical depression and these commonali- ties can be emphasized to assist the cJient inknowing she or he is not alane in such an illness. Simultaneously, while common experiences may be described, the client can also discuss the unique features of and, more

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specifically, the unique sources contributing to the depression. Contributing sources may range from interpersonal (e.g., marital) conflict to specific negative social experiences (e.g., racism, poverty).

To help clients reveal personal stories relative to the experience of depression, multiple strategies can be employed, including strategies that draw from the particular culture of a client. For example, some Hispanics may be familiar with "cuento" or folk tale therapy (Costantino, Malgady, & Rogler, 1985). In this process, folk tales are used, described as a means of assisting individuals with social learning. Perhaps such folk tales can help some Hispanic clients begin to recall and describe their own life experiences and, eventually, to describe the depressive experience.

SELF-MONITOR SELF-TALK AND EXAMINE UNDERLYING PERSONAL BELIEFS

Thtough storytelling, descriptive accounts of depression, clients can begin to understand the complex, compounding variables that initiate and/ or maintain depressive symptomology. With this background, clients can commence learning to self-monitor the active role of cognition in sustain- ing depressive symptoms, a third cognitive therapy process variable. "he goal of cognitive therapy is to increase the individual's awareness of negative or non-helpful perceptions. This does not imply that the percep- tions of depressed individuals are wrong, though perhaps more data or evidence can invite a more adaptive interpretation of an experience or event. The client who has experienced ethnic or racial discrimination is not expected to simply talk themselves away from the evidence, rather to evaluate the evidence in such a way as to assess responsibility and avenues of potential control. The cognitive therapy process can help culturally different clients distinguish personal responsibility from the imposed so- cial experience. In this process, increased self-awareness can be augmented by in-

creased social awareness such that monitoring self-talk might reflect social injustice 'or economic disparities rather than eliciting self-blame inap- propriately (or only). Further, the minority client can utilize such aware- ness to depersonalize some experiences or feedback. Of coucse, in this cognitive reframing process, it is not suggested to the client that the nega- tive behavior of others (e.g., discrimination, rejection, etc.) is acceptable, only that it happened at this point in time.

During this stage of the cognitive therapy process, culturally diverse clientele can also learn to manage a particular depressive cognitive style, "overgeneralization." A client can approach an experience with a particu-

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Judith L. Norman 83

lar cognitive modification, (e.g., from “all people treat me with disrespect or disregard” to “som people treat me with disrespect or disregard” or “this person treats me with disrespect and disregard”).

In the process of increasing self-awareness and appropriately managing self-talk (intrapersonal feedback), an examination of underlying belief systems occurs. Individuals are helped to look critically at longheld, learned beliefs about themselves. Certainly, for the minority client, these longheld, learned beliefs may reflect the majority’s view of the minority individual’s people, group, or ancestry. That acts of the majority oppress a minority through belittling, discrediting, and other diminutive behaviors does not make such descriptions of minorities factual. However, surely there are individuals of a racial or ethnic minority who have lived as if some imposed descriptions or classifications actually exist (reflected in self-fulfilling prophecy, learned helplessness, etc.).

Behaviors may lead to repeated compliance with imposed evaluations by others, so that an individual becomes convinced of the reality of the evaluation by others. To discover underlying, learned beliefs (i.e., schema) about oneself or one’s cultural group may help the minority clients assess more realistically, then modify, historically rooted, though inaccurate, des- criptors of his or her own group and of his or her own self.

As the cognitive therapy process continues, the individual then can identify and challenge faulty longheld beliefs with current, alternative evidence. Perhaps the client could be helped to identify positive role models within the minority culture or within the extended or immediate family that may help the minority client properly perceive variations in individual and group behavior and accomplishments. Obviously, such efforts require the education of the cognitive therapist regarding minority cultural differences and specific minority members that may be potential role models for minority clients. In this way, the cognitive therapy pro- cess continues to be collaborative with the therapist expecting that the client be the expert regarding his or her own personal experience with depression.

PUASANT ACTIVITIES

Engaging clients in pleasant activities as opposed to less pleasurable activities is a fourth cognitive therapy process variable. The client is trained to observe the correlation that as participation in pleasant activities increases, depression decreases. Of course, this inverse correlation de- pends upon improvement in other areas such as heightened energy levels, as well as stabilization of sleeping and eating patterns and other improve-

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ments. Such improvements in variable depressive symptoms are a matter of interaction effects with improved symptomology in one area positively impacting symptomology in another area (noted in the discussion of the Interactional Model of assessing and treating depression).

Pleasant activities could be broadened to include events and active participation in a variety of activities beyond the recreational. !&me mi- nority clients may wish to select participatian in small-scale or large-scale political processes that promote the rights and welfare of minorities. They may wish to participate in support groups which increase emotionally supportive experiences while, simultaneously, providing awareness or education around the availability and acquisition of resources and services for diverse (including minority) cultural populations. Such activities may provide the minority client with a sense of control or influence, and, in this way, create more positive perceptions of herself or himself or of her or his situation.

INTERPERSONAL SKILLS TRAINING, PROBLEM-SOLVING, RELAXATION TRAINING

The pleasant activities mentioned may lend support to both individual, as well as social, means of improved functioning. A fdth cognitive thera- py process variable includes interpersonal skills training and problem- solving skills training. In cognitive therapy processes in a group format, group members offer feedback as well as social support to one another. Minority clients may offer conrective feedback to majorityculture peers about the minority cultural experience. Likewise, group peers may be able to support minority clients in eliciting personal stories and offering some feedback as to means and places wherein necessary changes might be likely.

Throughout the group process, interpersonal interactions, mutual feed- back, and storytelling between minority and majority clients suffering from depression may be guided to take a dud perspective framework. That is, just as the cognitive therapy process generally calls for an evaluation of individual perspectives that may differ, majority and minority client group members can be assisted to stop and assess the perceptions/cognitions of one another, with a recognition that two views of a similar event may differ for independent cultural perspectives. This process suggests that neither perspective is necessarily wrong, merely different.

The interpersonal skills training and problem-solving Skills training can be accomplished especially well and simultaneously when a group process is the selected medium of therapy. Also, the group process pro-

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Judith L. Norman 85

vides a way for culturally diverse individuals to learn about one another and from one another. Allowing group members to assist one another in the problem-solving processes may be a positive model for problem- solving in the culture at large, the group experience serving as a social microcosm.

Relaxation training and guided imagery are additive process variables in cognitive therapy. Such techniques help the individual cope temporarily while longer term answers are sought. Relaxation training may reflect variable cultural or spiritual activities such as meditation, yoga, specific musical instruments or melody, chanting, etc., or other activities that pro- mote relaxed muscles, reduced tension, and bodily calm.

MEDZCATZON MANAGEMENT

Cognitive therapists can provide much in the way of reducing negative psychological processes and functioning. When biologicat symptoms are evident and moderate to severe, the cognitive psychotherapist can recom- mend .medication internention andor support the medical prescription of antidepressant medication. This is the sixth and frnal component of the cognitive therapy process. Part of the cognitive therapy process includes educating the client about possible biologic symptoms of depression and the possible usefulness of pharmacotherapy in reducing these biologic symptoms. Psychotherapist support of patient medication compliance can be extremely important in the overall reduction of depressive symptoms. This educational process again reminds the client of the interactional and complex nature regarding the features and symptoms of depression. Again, cultural attitudes toward the body and toward medication must be evaluated and subsequent support will reflect this cultural sensitivity.

Depressed clients of a variety of cultural minorities in the United States may wish to consult medicine men, medicine women, shaman, priests, or others regarding physical symptomology. Including feedback from such sources, in so far as possible, in the context of cognitive therapy can be additive to the positive progress or change sought.

Though biologic interventions are beyond the focus of this paper, it should be noted that responsiveness to medications (i.e., antidepressants) may vary across cultures and races. The research to date is limited, howev- er, h r e have been suggestions that medication dosages differ relative to culture, race, or ethnicity. Explanations for such variations include genetic differences, metabolic differences, therapist perception, and misdiagnosis,

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as well as medication compliance differences (Keh-Ming, Russell, and Nakasake, 1993; Kelmer and Folks, 1992).

SUMMARY

This paper has been a descriptive overview of the cognitive therapy process variables with special reference to the conducive qualities of this process to culturally sensitive implementation. Only a few illustrations have been provided, thus there is an invitation to elicit many illustrations from a wide variety of cultural populations, which would effectively aid cognitive therapists in treating the psychological symptomology of cultur- ally diverse and minority populations.

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