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.     

Attentional bias and emotional reactivity as predictors and moderators of behavioral treatment for social phobia

Cognitive behavioral therapy (CBT) is a well-established treatment for anxiety disorders, and evidence is accruing for the effectiveness of acceptance and commitment therapy (ACT). Little is known about factors that relate to treatment outcome overall (predictors), or who will thrive in each treatment (moderators). The goal of the current project was to test attentional bias and negative emotional reactivity as moderators and predictors of treatment outcome in a randomized controlled trial comparing CBT and ACT for social phobia. Forty-six patients received 12 sessions of CBT or ACT and were assessed for self-reported and clinician-rated symptoms at baseline, post treatment, 6, and 12 months. Attentional bias significantly moderated the relationship between treatment group and outcome with patients slow to disengage from threatening stimuli showing greater clinician-rated symptom reduction in CBT than in ACT. Negative emotional reactivity, but not positive emotional reactivity, was a significant overall predictor with patients high in negative emotional reactivity showing the greatest self-reported symptom reduction.     

Vocational interest structures for Asian Americans,Middle-Eastern Americans and Native Americans on the 2005 Strong Interest Inventory

This study examined whether the vocational interests of Asian Americans, Middle-Eastern Americans, and Native Americans, as measured by the 2005 Strong Interest Inventory (SII), followed Holland's (1997) calculus hypotheses for a RIASEC ordering. The structures of interests of these three racial/ethnic groups were examined for fit with two structural models: (1) a less-stringent model requiring a circular RIASEC ordering and (2) a more stringent model requiring equal distances between adjacent interest types. Individuals who completed the 2005 Strong Interest Inventory were included in the sample (N = 22,394), and the overall sample was divided between racial/ethnic groups, gender, and professional status (i.e. student and employed adults). Results from randomization tests of hypothesized order and circular unidimensional scaling analyses found that a circular RIASEC order is applicable to Asian American, Middle-Eastern American and Native American students and employed adults, regardless of gender, when measured by the 2005 Strong Interest Inventory. Results from this study indicate that the current version of the Strong Interest Inventory measures vocational interests in a manner that strongly aligns with Holland's calculus hypothesis for both men and women.     

Arab Americans With Disabilities and Their Families: A Culturally Appropriate Approach for Counselors

The authors present a brief introduction to Americans of Arab descent and a brief overview of Arab culture. Then, culturally appropriate counseling considerations related to family, attitudes toward disability, religion, communication, acculturation, help‐seeking behaviors, and stereotypes are highlighted. In the last section, the authors provide conclusions and recommendations for culturally appropriate considerations in working with Arab Americans with disabilities and their families. Los autores presentan una breve introducción sobre los americanos de origen árabe y un breve resumen de la cultura árabe. Después, se destacan consideraciones para la consejería culturalmente apropiada relacionadas con la familia, actitudes sobre discapacidad, religión, comunicación, aculturación, comportamientos de búsqueda de ayuda, y estereotipos. En la última sección, los autores proporcionan conclusiones y recomendaciones para consideraciones culturalmente apropiadas a la hora de trabajar con americanos de origen árabe con discapacidades y sus familias.     

Being American, being Asian: the bicultural self and autobiographical memory in Asian Americans

Studies of autobiographical memory have shown that the degree to which individuals focus on themselves vs. social relations in their memories varies markedly across cultures. Do the differences result from differing cultural self-views (i.e., an autonomous vs. a relational sense of self), as often suggested in the literature? Experimental evidence is required to answer this question. In the present study, Asian American participants (N=118) were primed to focus on their American or Asian self prior to recalling important autobiographical events, and participants in a control group described things in nature prior to the memory recall. Those whose American self was activated recalled more self-focused and less socially oriented memories than those whose Asian self was made salient, with the control group falling in between. The findings shed light on the mechanism underlying cultural influences on autobiographical remembering. They further highlight the dynamic nature of the memory-self interplay in cultural contexts.     

Culturally Informed and Flexible Family-Based Treatment for Adolescents: A Tailored and Integrative Treatment for Hispanic Youth

The increasing utilization of evidence-based treatments has highlighted the need for treatment development efforts that can craft interventions that are effective with Hispanic substance abusing youth and their families. The list of evidence-based treatments is extremely limited in its inclusion of interventions that are explicitly responsive to the unique characteristics and treatment needs of young Hispanics and that have been rigorously tested with this population. Some treatments that have been tested with Hispanics do not articulate the manner in which cultural characteristics and therapy processes interact. Other treatments have emphasized the important role of culture but have not been tested rigorously. The value of well designed interventions built upon an appreciation for unique patient characteristics was highlighted by Beutler et al. (1996) when they argued that "psychotherapy is comprised of a set of complex tasks, and practitioners need comprehensive knowledge of how different processes used in psychotherapy interact with patient characteristics in order to make treatment decisions that will maximize and optimize therapeutic power" (p. 30). A focus on how treatment processes interact with patient characteristics is particularly relevant in the Hispanic population because of the considerable heterogeneity beneath the Hispanic umbrella. Our new program of clinical research focuses on articulating how the varied profiles with regard to immigration stressors, acculturation processes, values clashes, sense of belonging to the community, discrimination, and knowledge about issues important to adolescent health can be more effectively addressed by a culturally informed treatment.     

Psychocultural Profiles of Asian and Pacific Islander Americans: Implications for Counseling and Psychotherapy

This article introduces Asian and Pacific Islander Americans as disparate groups of various ethnic and cultural backgrounds. From the perspective of culturally prescribed norms, standards, and values that affect the acculturation experiences and lifestyles of this ethnic minority group, some psychocultural profiles are presented. The relevant implications for counseling and psychotherapy are also suggested.     

Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.     

Denominational Differences in Support for Race-Based Policies Among White, Black, Hispanic, and Asian Americans

This study builds upon past studies of denominational culture and racial attitudes by positioning evangelicals as the basis of comparison when assessing denominational differences in American racial attitudes. The study also attempts to extend the theoretical contribution of religious culture and racial attitudes by assessing support for race-based policies among black, white, Hispanic, and Asian-American evangelical and nonevangelical Protestants. In short, arguments about a distinctive individualistic religious culture among evangelicals may be useful in explaining why white evangelicals maintain lower levels of support for policies aimed at reducing racial inequality than do mainline and secular whites. However, it is of less relevance in explaining the race-based policy attitudes of white evangelicals relative to white Catholics and among nonwhites as a whole.     

Behavioral Goals for a Diverse Organization: The Effects of Attitudes, Social Norms, and Racial Identity for Asian Americans and Whites

This research identified 5 behaviors that may enhance the effectiveness of a diverse organization and used Fishbein and Ajzen's (1975) theory of reasoned action to identify predictors of these behaviors. Results from samples of White and Asian undergraduate students from 2 universities generally supported the Fishbein and Ajzen model. Attitudes and subjective norms were significant predictors of behavioral intentions when gender, race, and social desirability bias were controlled. Racial identity also had a significant, positive effect on attitudes toward diversity-related behaviors among the Asian American students, but no significant effect among Whites. These results supported our reasoning that members of historically excluded racial groups with strong racial identities will be most likely to welcome organizational attempts to become more pluralistic because pluralism means that their valued identities will be respected rather than repressed.     

Attention to phobic stimuli during exposure: the effect of distraction on anxiety reduction, self-efficacy and perceived control

To replicate and extend the finding that distraction facilitates between session anxiety reduction (), 27 spider phobics underwent three 10-min sessions of in vivo exposure followed by one 10-min exposure session at a 4-week follow-up, while having either stimulus-relevant focused conversation or stimulus-irrelevant distracting conversation with the experimenter. Physiological arousal and subjective anxiety were measured during exposure, and self-efficacy, perceived control and performance on a behavioural task were measured at pre-treatment, post session-3, and follow-up. Monitoring and blunting coping styles were also measured at pre-treatment to assess their impact on treatment outcome. Despite equal physiological activation between the groups, those who underwent distracted exposure showed greater reductions in subjective fear within and between sessions, and showed greater increases in self-efficacy ratings, internal perceived control and performance on a behavioural task. Coping style did not interact with the effect of distraction or focusing during exposure, however blunters had less subjective anxiety reduction overall, particularly when they underwent focused exposure. Results are discussed in terms of the emotional processing model and self-efficacy theory.     

Time-limited desensitisation, implosion and shaping for phobic patients: A crossover study

A comparison was made of the short-term time-limited efficacy of three forms of behaviour therapy in phobic patients: Systematic Desensitization (in imagination), Implosion (in imagination) and Shaping, or Reinforced Practice. A block design was used, all patients receiving all treatments in randomised order. Improvement was measured behaviourally and by symptom rating scales. Differences emerged only on the behavioural measures: Shaping was significantly superior to Desensitisation, with Implosion between the two, and not significantly different from either. Comparison of treated with untreated phobias within subjects showed Shaping to be more specific than the other two forms of treatment. It was concluded that Implosion and Shaping are potentially useful types of therapy, worthy of further study and application.     

焦虑障碍的认知偏向矫正元分析:效果量、影响因素及中介检验

焦虑障碍的认知偏向矫正效果及作用机制是当前一个研究热点且有争议的主题。采用元分析、元回归分析并且组合两步结构方程元分析技术,探索认知偏向矫正对焦虑障碍干预的临床和亚临床有效性,分析可能的影响因素并考察认知偏向改变在认知偏向矫正(Cognitive Bias Modification,CBM)和焦虑症状之间的中介作用。元分析共纳入46篇文献,CBM对焦虑症状干预具有虽小但显著的效果量(包含非标准化测量:g=0.29;标准化测量:g=0.26,p0.001;压力任务后焦虑症状g=0.34,p0.001),对认知偏向有中等效果量(g=0.48,p0.001);干预范式、出版特征、实验环境是焦虑症状CBM效果量的调节因素,焦虑障碍类型和实验环境对CBM认知偏向效果量有调节作用;认知偏向改变在CBM干预与焦虑障碍改变之间起显著的中介效应(z=3.13,SE=0.014,p0.001),为部分中介。将来研究可关注提升CBM症状测量或者认知偏向测量工具的信效度、发展新干预范式,尝试CBM同其他干预方式相结合,进一步探索CBM理论基础和干预机制,提升干预效果。     

Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder

This study examined cognitive and affective predictors of treatment dropout and treatment efficacy in Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for PTSD. Study participants were women with PTSD from a sexual assault who received at least one session of either treatment (n = 145) as part of a randomized clinical trial. Results revealed that younger age, lower intelligence, and less education were associated with higher treatment dropout, whereas higher depression and guilt at pretreatment were associated with greater improvement in PTSD symptomatology. Results by treatment condition indicated that women with higher anger at pretreatment were more likely to dropout of PE and that older women in PE and younger women in CPT had the best overall outcomes. These findings have implications for efforts to enhance treatment efficacy and retention in CBT treatment protocols.     

'Fear of panic': an investigation of its role in panic occurrence, phobic avoidance, and treatment outcome

The concept of 'fear of fear' has recently received empirical attention regarding its role in panic occurrence and phobic avoidance. Overall, the results of such studies have indicated that anticipation of panic is positively correlated (albeit weakly) with self-reports of avoidance. The present study examined the relationship of panic anticipation--panic occurrence, phobic avoidance and treatment outcome, using a more direct measure of this fear than has been used in previous studies. Results indicated that anticipation of panic was slightly correlated with breadth and severity of avoidance, and moderately correlated with overall clinical severity. In addition, anticipation of panic was found to decrease significantly throughout treatment, but appeared to be independent of actual panic experience. These results may suggest the operation of an intervening variable which accounts for the reduction of both anticipated and actual panic events. Implications for assessment and treatment are discussed.     

The impact of dissociation and depression on the efficacy of prolonged exposure treatment for PTSD

This study investigates the impact of dissociative phenomena and depression on the efficacy of prolonged exposure treatment in 71 patients with posttraumatic stress disorder (PTSD). Diagnoses, comorbidity, pretreatment depressive symptoms, PTSD symptom severity, and dissociative phenomena (trait dissociation, numbing, and depersonalization) were assessed at pretreatment using semi-structured interviews and questionnaires. In a pretreatment behavioral exposure test, patients were imaginally exposed to (part of) their trauma memory for 9 min, during which subjective fear was assessed. At posttreatment and 6 months follow-up PTSD, depressive and dissociative symptoms were again assessed in the completers (n = 60). Pretreatment levels of dissociative and depressive symptoms were similar in dropouts and completers and none of the dissociative phenomena nor depression predicted improvement. Against expectations, dissociative phenomena and depression were associated with enhanced rather than impeded fear activation during the behavioral exposure test. However, these effects disappeared after controlling for initial PTSD severity. Hence, rather than supporting contraindication, the current results imply that patients presenting with even severe dissociative or depressive symptoms may profit similarly from exposure treatment as do patients with minimal dissociative or depressive symptoms.