Enhancing CBT Consultation With Multicultural Counseling Principles

The use of multicultural principles to enhance cognitive behavioral therapy (CBT) for individuals of marginalized backgrounds has received increased attention in light of the heightened national awareness of systemic oppression and racialized violence directed towards Black, Indigenous, and People of Color. However, there has been less of a focus on applying such principles to consultation for skill development. If ethical guidelines are expected to influence the behavior of clinicians in session, guidance is needed to indicate how and where and when clinicians should receive training in implementing culturally responsive CBT. Individual reading and reflection are necessary but are not sufficient in acquiring new clinical skills. Consultation is recommended and strongly suggested when clinicians are working with new populations or delivering a new treatment, or even using a new modality. Consultation can also be useful when adopting a new approach or stance to therapy. For practicing clinicians who have not developed these skills, additional consultation can and should be used to address this gap. Moving forward, integration of cultural responsiveness into standard consultation will ensure that these skills are seen as a core competency, rather than an optional additional skill that may be (or not be) elected. This paper presents core experiences that may be integral to a CBT consultation model that aims to enhance providers’ ability to provide CBT in a way that is culturally responsive to their clients. These recommendations attend to both content and process within CBT consultation and reflect guiding assumptions for helping clinicians to develop the ability to practice CBT in a culturally responsive manner, including (a) normalizing discussions of cultural identity and oppression, (b) an emphasis on cultural self-awareness, (c) emphasizing culturally informed CBT case conceptualization, and (d) skill development in applying cultural elements to CBT interventions.     

“We are better and happier if we are inclusive.” Therapist perspectives on the importance of LGB cultural competence in a mental health setting

Lesbian, gay and bisexual people are more likely than their heterosexual counterparts to report dissatisfaction after accessing a counselling or psychological service. Greater dissatisfaction may result from therapists who focus on psychopathology without considering cultural context. Research has demonstrated therapists' cultural competence (attitudes, knowledge and skills) may influence effective service provision to LGB people. Counsellors and psychologists (N = 10) were interviewed to determine the sources of information influencing the cultural competence and LGB cultural competence practices used by therapists in their clinical practice. Three themes were developed from semistructured interviews: (1) the importance of multiple sources of cultural competence; (2) applying cultural competence improves the therapeutic process; and (3) ensuring visual cues of affirmation are affirming, not pathologising. Theme 1 highlighted that initial professional training, cultural competence training and lived experience could be triangulated to assist therapists in improving their cultural competence. Theme 2 highlighted that cultural competence improves the therapeutic process by ensuring therapists can demonstrate affirming attitudes, knowledge about LGB people and culturally affirming skills to work effectively with LGB clients. The final theme explored the need for therapists to create an inclusive space for LGB clients. Recommendations for improving clinical practices and tools to enhance cultural competence are discussed.     

Evidence-based treatment research: Advances, limitations, and next steps

This article highlights the development of evidence-based treatments (EBTs), the accomplishment their development reflects, and the limitations of current variations as a way of providing mental health services and care. Rather than review EBTs, I use the occasion to provide an overview of my work on the development of treatments for children referred clinically for aggressive and antisocial behavior. This work reflects a larger genre of intervention research that has developed treatments for a variety of disorders. After years of research and a healthy list of EBTs, where are we and where do we need to be? It is still the case that most people in need of services do not receive them, and disparities in providing services remain enormous. The vast majority of therapies, whether evidence based or not, use a model of delivery (one-to-one in-person treatment) that is inherently limited as a way of reaching the large swath of people in need of services. Multiple models of delivery of treatment are needed. The article underscores the importance of developing these models of delivery and optimizing that development by understanding better the mechanisms of therapeutic change. (PsycINFO Database Record (c) 2011 APA, all rights reserved).     

When the Evidence Says, "Yes, No, and Maybe So": Attending to and Interpreting Inconsistent Findings Among Evidence-Based Interventions

ABSTRACT— An international, multidisciplinary effort aims to identify evidence-based treatments (EBTs) or interventions. The goal of this effort is to identify specific techniques or programs that successfully target and change specific behaviors. In clinical psychology, EBTs are identified based on the outcomes of randomized controlled trials examining whether treatments outperform control or alternative treatment conditions. Treatment outcomes are measured in multiple ways. Consistently, different ways of gauging outcomes yield inconsistent conclusions. Historically, EBT research has not accounted for these inconsistencies. In this paper we highlight the implications of inconsistencies, describe a framework for redressing inconsistent findings, and illustrate how the framework can guide future research on how to administer and combine treatments to maximize treatment effects and how to study treatments via quantitative review.     

Evidence-based psychological treatments for late-life anxiety

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults.     

Using Mindfulness- and Acceptance-Based Treatments With Clients From Nondominant Cultural and/or Marginalized Backgrounds: Clinical Considerations,Meta-Analysis Findings,and Introduction to the Special Series: Clinical Considerations in using Acceptance- and Mindfulness-based Treatments With Diverse Populations

A growing body of research suggests that mindfulness- and acceptance-based principles can increase efforts aimed at reducing human suffering and increasing quality of life. A critical step in the development and evaluation of these new approaches to treatment is to determine the acceptability and efficacy of these treatments for clients from nondominant cultural and/or marginalized backgrounds. This special series brings together the wisdom of clinicians and researchers who are currently engaged in clinical practice and treatment research with populations who are historically underrepresented in the treatment literature. As an introduction to the series, this paper presents a theoretical background and research context for the papers in the series, highlights the elements of mindfulness- and acceptance-based treatments that may be congruent with culturally responsive treatment, and briefly outlines the general principles of cultural competence and responsive treatment. Additionally, the results of a meta-analysis of mindfulness- and acceptance-based treatments with clients from nondominant cultural and/or marginalized backgrounds are presented. Our search yielded 32 studies totaling 2,198 clients. Results suggest small (Hedges' g = .38, 95% CI = .11 – .64) to large (Hedges' g = 1.32, 95% CI = .61 – 2.02) effect sizes for mindfulness- and acceptance-based treatments, which varied by study design.     

Commentary on Koons et al.’s (2013) “Negotiating for Improved Reimbursement for Dialectical Behavior Therapy: A Successful Project”

This paper provides a commentary of Koons, O’Rourke, Carter, and Erhardt (this issue), which takes an inspiring first step in bridging research and clinical practice. We encourage the field to take the following from this paper: (a) evidence-based treatment (EBT) can work in real-world settings; (b) publishable research can be accomplished in a purely clinical environment; (c) some insurance companies are willing to pay more for EBTs; and (d) getting sufficient pay for more time-consuming work has potential to help patients. Koons et al. found the crucial synthesis for all clinicians: In a purely clinical setting, research demonstrated that people got better and the providers were paid more for their work.     

Using a Learning Collaborative Model to Disseminate Cognitive Processing Therapy to Community-Based Agencies

Although effective treatments for posttraumatic stress disorder exist, their use in community settings is disappointingly low. Training alone does not necessarily lead to adoption. To address this problem, we trained community clinicians in cognitive processing therapy, an evidence-based treatment for posttraumatic stress disorder, using a Learning Collaborative, an intensive training methodology focused on both clinical training and developing sustainability. Sixty clinicians within 18 agencies began the year-long, team-based Learning Collaborative. Clinicians attended three in-person Learning Sessions, received weekly consultation, and submitted audio-recorded sessions to be rated for fidelity. Clinicians were rostered as approved treatment providers if they completed all training requirements. Additionally, we engaged leadership from each agency to build a sustainable practice. Clinicians trained through the Learning Collaborative demonstrated a high degree of fidelity to the treatment (average competence ratings “satisfactory” to “good”), and most (68%) were rostered as approved treatment providers. Patients treated by clinician trainees exhibited significant symptom reductions (d = 1.68 and 1.28 for posttraumatic stress and depression symptoms, respectively, among treatment completers). At a 6-month follow-up, 95% of rostered clinicians and 100% of agencies with rostered clinicians were still providing the treatment. These results suggest that the Learning Collaborative model is a promising approach for the dissemination and implementation of evidence-based treatments for adult posttraumatic stress disorder.     

Implementation and Dissemination of Military Informed and Evidence-Based Interventions for Community Dwelling Military Families

Community dwelling military families from the National Guard and Reserve contend with deployment-related stressors in relative isolation, living in communities where mental health providers may have little knowledge of military culture. When they are community residents, active duty service members and families tend to live in close proximity to their military installations. This article will focus primarily on the challenges to quality mental health care for reserve component (RC) families. Where studies of RC families are absent, those of active component (AC) families will be highlighted as relevant. Upon completion of a deployment, reintegration for RC families is complicated by high rates of symptomatology, low service utilization, and greater barriers to care relative to AC families. A paucity of providers skilled in evidence-based treatments (EBTs) limits community mental health capacity to serve RC military families. Several emergent programs illustrate the potential for better serving community dwelling military families. Approaches include behavioral health homes, EBTs and treatment components, structured resiliency and parent training, military informed schools, outreach methods, and technology-based coping, and psychoeducation. Methods from implementation science to improve clinical skill acquisition and spread and sustainability of EBTs may advance access to and quality of mental health treatment and are reviewed herein. Recommendations related to research methods, military knowledge and treatment competencies, and transition to a public health model of service delivery are discussed.     

Culturally Adapted Psychosocial Interventions for Schizophrenia: A Review

Recent research examining the potential efficacy of culturally adapted interventions for various mental disorders illustrates increasing interest in the integration of cultural perspectives into mental health systems. Despite recent evidence demonstrating that culturally adapted interventions may be more effective than a one-size-fits-all approach, few psychosocial treatments for schizophrenia consider cultural factors that may enhance their efficacy with diverse populations. The aim of this review is to discuss the empirical evidence examining the potential utility of culturally adapted group interventions for schizophrenia, as a means to encourage further work and expansion in this area. Specifically, this article provides an in-depth review of the empirical literature on culturally adapted psychosocial interventions for individuals with schizophrenia and their family members, with a focus on group-based interventions. This review is followed by a discussion of a few cultural constructs that may impact patient and family member functioning, and therefore may be important to address in psychosocial treatments for schizophrenia. Finally, we end this review with a broad discussion of research limitations and potential areas for additional research, clinical implications for adapting EBTs to better address cultural concerns, and a case vignette to illustrate how cultural considerations can be integrated into a traditional multifamily group therapy approach.     

Culturally Attuned Behavior Therapy for Anxiety and Depression in Asian Americans: Addressing Racial Microaggressions and Deconstructing the Model Minority Myth

Extant research has shown that racial discrimination and microaggressions can have negative effects on anxiety and depression among Asian Americans. However, not much has been published regarding how to process and integrate experiences of racism into culturally attuned behavior therapy specifically for Asian Americans. In this article, I describe the process of culturally attuned behavior therapy for two Asian American clients, with an emphasis on integrating racial microaggressions into exposures for social anxiety, and deconstructing the model minority stereotype through value-driven behavioral activation for depression. Cultural attunements common to both case examples are then summarized, alongside practical recommendations for clinicians. Limits to generalizability are also discussed. Finally, the article closes by addressing the importance of cultural humility in effective culturally attuned behavior therapy with Asian Americans.     

Working Through Countertransference Blocks in Cultural-Competence Training

The encounter with clients from diverse cultural backgrounds may stir in the practitioners intense counter-transferencial reactions, which if unexplored may obstruct the helping relationships and interventions. This article presents and demonstrates a cultural competence training where such countertransference can be worked through. The training applies a combination of narrative analysis that emphasizes the active participation of the listener in the sense-making process and of the exploration of group processes from a psychoanalytically oriented point of view. Presented are four vignettes that demonstrate different types of countertransference and of the group process.     

Cultural Considerations for Psychologists in Primary Care

Many health concerns in the United States (e.g., diabetes) are routinely managed in primary care settings. Regardless of the medical condition, patients’ health is directly influenced by factors such as healthcare providers and cultural background. Training related to how behaviors influence health, coupled with training on how cultural diversity intersects with mental health, allows psychologists to have the relevant expertise to assist in the development of primary care behavioral health interventions. However, many psychologists in primary care struggle with how to integrate a culture-centered paradigm into their roles as behavioral health providers. This paper provides an introduction on how three culture-centered concepts (providers’ cultural sensitivity, patient–provider cultural congruency, and patients’ health literacy) can be applied in primary care using the Five A’s Organizational Construct and a model of cultural competence. In addition, the paper includes a section on integration of cultural considerations into consultation and training and concludes with a discussion of how the three culture-centered concepts have implications for health equity.     

Preparing Families for Evidence-Based Treatment of ADHD: Development of Bootcamp for ADHD

Objective: Many families of children with attention-deficit/hyperactive disorder (ADHD) do not initiate evidence-based treatments (EBTs), placing these children at risk for poor outcomes. Bootcamp for ADHD (BC-ADHD) is a novel, four-session, group intervention designed to prepare parents as informed consumers to engage in multimodal EBTs for ADHD. This paper describes the theory of change and the development of BC-ADHD, outlines its components, and provides an initial proof of concept of the program. Method: Participants were 11 families of children with ADHD (ages 5–11; 55% male; 91% non-Hispanic; 55% White, 27% Black, 18% more than one race) who were the initial participants receiving BC-ADHD during a small-scale, randomized controlled trial. Parent-report outcome measures assessed parental empowerment, treatment preferences, affiliate stigma, intention to pursue treatment, and treatment initiation at baseline, posttreatment, and 6-week follow-up. Results: Parent engagement was high, as indicated by an 86% session attendance rate and high ratings of program satisfaction. Parents reported an increase in empowerment to access systems of care. Ratings of acceptability for behavior therapy increased at posttreatment and follow-up with minimal or no concerns about feasibility. The acceptability of medication was high at each assessment, although parents expressed increased concerns about stigma and adverse effects of medication at posttreatment and follow-up. Nonetheless, there was a marked increase in parental intention to use medication at posttreatment and follow-up. Accounting for ceiling effects, parents reported substantial increases in intention to use medication, behavioral parent training (BPT), and school services. Changes in treatment initiation were in the expected direction. Conclusions: BC-ADHD has the potential to promote family empowerment in seeking services and increase their intent to initiate EBTs, as well as actual initiation of these treatments.     

A Novel Approach to the Assessment of Fidelity to a Cognitive Behavioral Therapy for PTSD Using Clinical Worksheets: A Proof of Concept With Cognitive Processing Therapy

Fidelity monitoring is a critical indicator of psychotherapy quality and is central to successful implementation. A major barrier to fidelity in routine care is the lack of feasible, scalable, and valid measurement strategies. A reliable, low-burden fidelity assessment would promote sustained implementation of cognitive behavioral therapies (CBTs). The current study examined fidelity measurement for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) using clinical worksheets. External raters evaluated patient worksheets done as a part of treatment, both guided by the therapist and completed independently as homework. Results demonstrated that fidelity ratings from CPT session worksheets were feasible and efficient. Notably, they were strongly correlated with observer ratings of the fidelity of CPT strategies that were present on the worksheets. Agreement among ratings conducted by individuals with a range of experience with CPT was acceptable to high. There was not a main effect of therapist-guided, in-session worksheet ratings on PTSD symptom change. However, patient competence in completing worksheets independently was associated with greater PTSD symptom decline and in-session, therapist-guided worksheet completion was associated with larger symptom decreases among patients with high levels of competence. With further research and refinement, rating of worksheets may be an efficient way to examine therapist and patient skill in key CPT elements, and their interactions, compared to the gold standard of observer ratings of therapy video-recordings. Additional research is needed to determine if worksheets are an accurate and scalable alternative to gold standard observer ratings in settings in which time and resources are limited.     

Multicultural Training Experiences as Predictors of Psychology Students' Cultural Competence

The psychologists in the western world, including Australia, are required to be culturally competent because of the cultural diversity of these societies. Previous studies conducted in North America and Europe have found multicultural teaching, clinical experience with culturally diverse clients, and discussion of multicultural counselling issues in supervision to be related to the practitioner's cultural competency. The present study examined factors contributing to trainee psychologists' perceived level of cultural competence. It was hypothesised that multicultural teaching, clinical experience, and supervision would be related to students' level of cultural competence. One hundred twenty‐seven postgraduate clinical psychology students completed an online survey battery that included demographic information, a social desirability measure, and the Multicultural Mental Health Awareness Scale. This hypothesis was partially supported. Clinical experience and supervision focusing on multicultural issues were found to be related to participants' perceived cultural competence; however, multicultural teaching was not. These results provide insight into how universities around Australia can facilitate future psychologists' competence in working with clients from different cultural backgrounds.     

Understanding Latina Immigrants Using Relational Cultural Theory

Latina immigrants face a number of challenges as they adapt to their new culture. This article presents Relational Cultural Theory (RCT) as a model for understanding the challenges Latina immigrants may present in psychotherapy. The RCT concepts of mutual empathy and empowerment, connections, condemned isolation, the central relational paradox, and power-over dynamics are used to understand the challenges Latina immigrants experience. Sociopolitical and cultural factors that interact to produce power-over dynamics are identified to show how Latina immigrants are at increased risk for major disconnections. A vignette shows how clinicians can use RCT to provide more culturally relevant treatment in their work with Latina immigrants.