Cognitive-Behavioral Therapy for Ethnic Minorities

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Table of Contents

Overview
Quantitative Research
Qualitative Research
Program Evaluation Articles
Implications of the Research for Practice
References

Overview

Cognitive-behavioral therapy (CBT), as a counseling approach, takes into account an individual’s beliefs, behaviors, and thought processes during a psychotherapy session. In this approach, a counselor works with a client to discover unconstructive personal behaviors and beliefs and replace them with realistic thought patterns.

The aim is to alter specific thoughts and behaviors in order to transform a client’s feelings. Culturally aligned CBT approach has been used to treat depression and different anxiety disorders in ethnic minority clients.

In this paper, the efficacy of CBT in counseling ethnic minorities is investigated through a review of recent literature to identify the qualitative and quantitative research evidence for its use. It evaluates each study’s design, procedure, sample selection, and data analysis and interpretation to find out the degree of empiricism used in the research.

The evaluation has implications for CBT-based interventions applied to ethnic minority clients.

Quantitative Research

Most quantitative studies support the use of CBT to treat various anxiety, PSTD, and depressive disorders. In a quantitative research article by Dwight-Johnson et al. (2011), the efficacy of a modified CBT used to improve the depression outcomes of 101 Latino clients residing in far-flung areas in Washington was evaluated.

The research design involved a randomized control trial/study (RCT) of phone-based CBT applied to Latino patients receiving care in a community clinic (Dwight-Johnson et al., 2011). The researchers used this approach to compare the effectiveness of CBT over standard care (antidepressant therapy) in promoting the outcomes of the subjects.

The RCT design was appropriate as the study sought for a cause-effect relation between phone-based CBT and depression outcomes.

The research site was a rural health clinic (called Yakima Valley Medical Center) serving Latino patients. The researchers trained bilingual locals to recruit patients exhibiting depression symptoms, but without any cognitive, mood, or psychotic disorders.

Randomized groups of the recruited patients received eight sessions of phone-based CBT in Spanish/Latino. A CBT workbook adapted to suit the Latino culture was sent to therapists involved in the intervention.

The intervention focused on strategies to improve “behavioral activation and eliminate negative thoughts” (Dwight-Johnson et al., 2011, p. 939). The subjects’ depression outcomes were evaluated using a patient health questionnaire administered in two interview sessions (baseline and follow-up).

The study involved a convenient sample of 101 minority patients receiving care in a community-based clinic. The sampling technique used was convenience sampling, whereby the research assistants recruited eligible adult patients to participate in the study.

The subjects had to be Latino/Spanish speakers and patients with depressive disorders, but free of bipolar, cognitive, and psychotic disorders. These broad inclusion criteria ensured a representative sample as all eligible subjects from the accessible population could qualify to participate.

Additionally, the exclusion criteria used ensured that subjects with conditions (e.g., Bipolar) that may confound the outcomes of CBT were not enrolled.

The researchers used two statistical measures, namely, t-test and chi-square test to compare the depression outcomes of the two groups based on the interview data.

They created a model based on the assessment of the outcomes of the two interventions at four periods (a categorical variable), namely, “baseline, six weeks, three months, and six months” (Dwight-Johnson et al., 2011, p. 941).

The results indicated that the ‘mean difference’ in depression outcomes between the group receiving standard care and the one under CBT for six months was 0.32. This implies that CBT, in combination with standard care, can enhance the outcomes of depressed minority clients.

However, this result was not statistically significant owing to the limited sample size used.

Ethnic minorities have an elevated risk of developing psychotic disorders due to discrimination. In an article, Rathod et al. (2013) assessed the efficacy of a CBT-based intervention modeled to treat psychosis in ethnic minority clients.

In this study, 33 subjects drawn from three ethnic minority groups in the UK, namely, African Caribbean, Black British, and Muslim communities participated in the research.

The design used was randomized controlled trial, whereby the subjects were randomly assigned to two groups, namely, the standard care (control) and CBT (experimental) (Rathod et al., 2013).

By comparing the outcomes of the two groups, the researchers were able to assess the efficacy of CBT in treating minority clients with psychotic disorders.

The study was conducted at two sites in the United Kingdom and involved subjects diagnosed with a psychotic disorder. The evaluation of their symptoms was done at the start of the CBT intervention, after the intervention, and at six-months after completing the treatment.

At each point, the researchers evaluated their outcomes using two assessment tools: “the comprehensive psychopathological rating scale (CPRS) and the insight scale” (Rathod et al., 2013, p. 321).

In addition to completing these scales, subjects in the CBT group filled a patient experience questionnaire to indicate their views about the treatment. The CBT group received sixteen sessions of cognitive-behavior therapy offered by a counselor while the standard care group received drug therapy.

In this study, both the subjects and the assessors were blinded, which reduced bias in comparative testing.

The sampling procedure employed in this study was purposive sampling. A sample of 35 participants was selected from two medical clinics based on specific inclusion criteria. Eligible participants had to be from the ethnic minority groups in the UK. Additionally, only patients with a diagnosable psychotic disorder were included.

Two participants who did not meet the inclusion criteria were excluded after the screening process. The remaining 33 were randomly selected into two subgroups of 17 (standard care) and 16 (CBT).

Data analysis involved intention to treat (ITT) and sensitivity assessments. The results indicated that the CBT (intervention) group had significantly reduced symptoms compared to the standard care group (Mean = 16.23 vs. 18.60), a difference of 11%.

The subjects in the intervention group had reduced delusions and hallucinations after completing the CBT sessions. Additionally, the CBT group reported high satisfaction with the intervention. These findings affirm the use of CBT to treat ethnic minority clients with psychosis.

A comparison between moderately and severely depressed individuals can give insights into the efficacy of CBT versus drug therapy.

A study by Saddique, Chung, Brown, and Miranda (2012) aimed at establishing whether the level of depression influences the effectiveness of CBT versus antidepressants in the treatment of depressed young minority groups.

The research design involved a randomized control trial of economically disadvantaged young black and Latina women. This design enabled the researchers to assess the post-treatment effects of CBT versus medication between the severely depressed and moderately depressed groups.

The sample comprised of women who were from diverse minority groups, uninsured, and having a diagnosable depressive disorder. Data collection occurred at six months and at one year. Baseline depression levels of the participants were obtained using the Hamilton Depression Rating Scale (HDRS).

Participants diagnosed with depressive disorders (n = 267) were randomly selected into three groups: “CBT, medication therapy, and community referral” (Saddique et al., 2012, p. 998).

The medication group (n = 88) was given an antidepressant (paroxetine) while the CBT arm (n = 90) underwent eight sessions of therapy. The community referral arm (n = 89) received mental health education from clinicians. Data collected using the HDRS were grouped into different categories based on depression levels.

Analysis involved growth mixture modeling to compare the effects of CBT, community referral, and drug therapy.

The results indicated that, for the severely depressed arm, on average, depression levels were higher in the CBT group than the drug therapy group after six months (14.9 vs. 13.9). However, this differential effect was not statistically significant after one year.

For the moderately depressed arm, the depression levels were again higher for the CBT group than the drug therapy group. These results indicate that drug therapy is more effective than CBT in the treatment of moderately depressed women from minority groups.

However, CBT administered for over six months appears to be superior to drug therapy in improving the outcomes of severely depressed clients.

Group-based CBT is a common intervention for treating substance addiction. A quantitative study by Webb et al. (2010) investigated the effectiveness of group-based CBT for reducing tobacco addiction among African Americans.

The researchers hypothesized that abstinence would be higher in the CBT group than in the general education condition. The study design involved a randomized control trial of adult smokers categorized into two groups: the CBT and health education arms (Webb et al., 2010).

The effects of smoking are relatively high among African Americans compared to other ethnic groups. Health education interventions have been found to be less effective. Therefore, by randomizing the subjects to CBT and health education groups, the study was able to evaluate the efficacy of CBT for this demographic.

A convenient sample of 154 adult male and female participants (smokers) participated in this study. They were randomized into the general health awareness condition and the CBT group (Webb et al., 2010). Both groups received six therapy sessions and continuous drug therapy.

The prevalence of abstinence was measured weekly for six months and the data treated to intent-to-treat analyses. The results indicated that post-counseling abstinence was significantly higher among the participants in the CBT group than in the general education subjects after seven days and six months.

This finding was consistent with the study’s hypothesis. The researchers concluded that group-based CBT is effective in treating nicotine addiction among African Americans.

Effective psychotherapy interventions must be culturally adapted to reflect the values and needs of the target minority population. In one study, Cachelin et al. (2014) investigated the efficacy of a CBT program modified to reflect the needs of Mexican American clients.

The research used a quantitative research design (cohort study) to assess the efficacy of the program in reducing binge eating among Mexican American women diagnosed with the problem. The approach allowed the researchers to compare the outcomes of the participants after undergoing CBT counseling sessions for three months.

A sample of 31 women drawn from the Mexican American population in LA participated in the study. A diagnosis of any binge eating disorder and Mexican American racial background formed the inclusion criteria.

The recruited participants went through eight counseling sessions based on a modified CBT program offered in a three-month period. The post-treatment variables measured included “binge eating, psychological functioning, and weight loss” (Cachelin et al., 2014, p. 451).

The study used intent-to-treat analyses to evaluate the data. The results indicated better outcomes in terms of reduced distress, body weight, eating disorders. Participants were also satisfied with the intervention. This implies that a culturally sensitive CBT is effective in treating binge eating disorders among ethnic minority women.

Qualitative Research

The dropout rate among minority clients undergoing CBT treatment is usually high, which leads to low health outcomes. A study by Rathod, Kington, Phiri, and Gobbi (2010) aimed at exploring the cultural values and attitudes that affect the efficacy of CBT applied to ethnic minorities.

The study used a qualitative research design to explore the views and attitudes of the participants towards CBT therapy. The approach was appropriate for examining subjective views in order to gain insight into the patient-related factors that affect CBT outcomes.

The sample (n = 114) was selected from two medical centers in the UK. It consisted of three ethnic minority groups: Black British, African-Caribbean, and Asian British (Rathod et al., 2010). The participants were schizophrenics receiving CBT therapy in the two centers.

The researchers used semi-structured interviews and focus groups to explore the participants’ understanding of the program and the cultural factors that underlie psychotic disorders. Data analysis involved the thematic approach.

The results indicated that most participants held the view that CBT-based interventions that incorporate cultural values and beliefs were useful in treating psychosis. The authors concluded that individualization of CBT therapy requires counselors to understand client-specific and cultural factors that affect its outcomes.

Patient feedback indicates that a culturally structured CBT can increase the outcomes of ethnic minority clients. Jackson, Schmutzer, Wenzel, and Tyler (2006) compared the views of two patient groups under CBT therapy, namely, European Americans and Indians.

The aim of the research was to evaluate the relevance of cognitive behavioral therapy based on the patient ratings of the intervention. The researchers noted that minority patients had certain preferences for CBT and thus, an exploration of the views would inform a culturally suited cognitive-behavioral intervention.

A sample of 52 adult participants drawn from the American Indian and European immigrant population was selected for the study. Their views and opinions were collected using an instrument called the cognitive behavior therapy applicability scale (Jackson et al., 2006).

In this study, the participants ranked their preference for particular aspects of the CBT that they believed suited their cultural context. The three domains that the study explored included active stance, in-session interactions, and formal relationships.

The results suggested that more European American participants preferred a CBT approach that emphasized on “in-session behavior and structured relationship” than American Indians (Jackson et al., 2006, p. 512). On the other hand, both client groups preferred a CBT that required their participation.

Thus, in practice, an effective CBT intervention for American Indians should focus more on active participation than on formal therapeutic relationships.

The efficacy of CBT also depends on the cultural competence of the therapists. An observational study by Shen, Alden, Sochting, and Tsang (2006) explored the efficacy of CBT program prepared in Cantonese language and offered in English to Chinese immigrants.

The aim was to establish whether the CBT assessment procedures were the best for this demographic. The researchers hoped that this would give insights into the type of changes that could be made to the program to enhance depression outcomes of the Chinese clients.

The sample was selected from Chinese immigrants living in Vancouver (Canada) and suffering depressive disorders. Researcher observations indicated that the standard evaluation and treatment procedures were not the best for this population.

In particular, the adaption of the tenets of the CBT from its original version (Cantonese) to English was not optimal. Additionally, the program’s “cognitive modification strategies” failed to consider the beliefs and cultural practices of the Hong Kong immigrants.

The assessment of depression levels was not reflective of the Hong Kong cultural context. This affected the efficacy of the adapted CBT in improving the depression outcomes of Hong Kong immigrants.

Patients at risk of depression, such as adolescents, can benefit from CBT-based interventions. A qualitative study by Duarte-Velez, Bernal, and Bonilla (2010) explored the views of an adolescent lesbian Latino girl who was diagnosed with ‘major depression’ disorder.

The study examined whether a manual-based CBT was consistent with the adolescent’s “sexual identity, family values, and spiritual ideas” (Duarte-Velez et al., 2010, p. 899). The aim of the research was to find out whether CBT was optimal for lesbian minority groups by assessing the participant’s views regarding the intervention.

Using the interviewing method, the researchers explored the role of CBT in improving individual acceptance of homophobia in the family context. The results indicated that CBT enhanced integration and personal acceptance of anti-homosexual views and actions perpetrated by family members.

Furthermore, CBT helped the participant to develop a sexual identity, which resulted in a decline in depression symptoms. One limitation of this study was the small number of participants used. A second limitation of the research was the use of only a female participant, which affected the external validity of the findings.

The validation of the CBT adapted for minorities is often problematic. An exploratory study by Bennett and Babbage (2014) examined the suitability of CBT for Aboriginal clients in Australia. They explored the belief that CBT should be modified to reflect the needs of the individual client in order to achieve positive outcomes.

The study examined aspects of the Aboriginal culture that were incongruent with the tenets of the CBT interventions. In particular, “kinship orientation and collectivism” were the key aspects of the Aboriginal culture that the researchers found to be important in a CBT intervention (Bennett & Babbage, 2014, p. 24).

This indicates that a CBT tailored to these values can yield positive outcomes for Aboriginal Australian suffering mental illnesses.

A comparable study by Weiss, Singh, and Hope (2011) explored the efficacy of CBT in the treatment of anxiety disorders in two immigrant patients. The study used a case study approach to assess the views of the clients on the efficacy of an individualized CBT intervention.

Data collection involved semi-structured interviews, whereby the clients rated the utility of the intervention in helping them overcome social anxiety disorder.

The findings suggested that a CBT protocol could be adapted to suit the needs of clients with diverse cultural backgrounds or non-native English speakers without changing many elements of the intervention.

Program Evaluation Articles

A few articles have evaluated culturally sensitive CBT adapted for the treatment of ethnic minority clients with different disorders. An article by Bennett-Levy et al. (2014) evaluated the effectiveness of “high and low versions of CBT” in treating Aboriginal Australians with mental disorders (p. 5).

The study employed a participatory research approach to collect the views of Aboriginal counselors regarding their perceived usefulness of a CBT program in treating Aboriginal Australian clients. Five trained counselors administered CBT therapy to clients in 10 sessions and evaluated its effect on patient outcomes.

In this study, the counselors evaluated the program based on three main aspects, namely, its usefulness for Aboriginal clients, adaptations that enhanced its efficacy, and specific elements of the program that were effective.

Data manipulation involved transcription and thematic analysis. The results indicated that CBT is a useful intervention for treating Aboriginal clients. Additionally, the counselors reported that CBT improved their counseling skills and wellbeing (Bennett-Levy et al., 2014).

It also reduced burnout and improved the outcomes of the clients. The counselors found CBT to be a pragmatic, highly adaptable, and valuable approach for treating minority clients. Other aspects of the CBT that enhanced its effectiveness included its compatibility with low-intensity interventions and safety.

Thus, it can be concluded that CBT adaptations that reflect cultural contexts are effective counseling techniques.

Trauma focused CBT (TF-CBT) is another popular therapy for molested minors. Strasser (2015) evaluated a TF-CBT adapted for sexually abused minority children.

Child abuse victims suffer PTSD, shame, and multiple anxiety-related disorders. TF-CBT is founded on research evidence and thus, follows specific guidelines for assessing psychological disorders in abused children.

Strasser’s (2015) study evaluated the program based on the evidence-based criteria to determine if it is applicable to abuse victims.

The evaluation established that TF-CBT is an evidence-based approach. A bounty of research supported the use of this intervention for minors suffering from trauma. Additionally, TF-CBT was effective in reducing depression and anxiety in culturally diverse clients.

In particular, the program’s adaptations were found to be effective for treating trauma in two minority cultures, namely, American Indian and Latino. However, the researcher identified aspects of TF-CBT adaptations that limited its effectiveness. Its efficacy for treating anxiety and depression disorders dwindled after 12 months.

In addition, the program did not take into consideration the clients’ preferences and attributes, which limited its efficacy when treating trauma children with hearing impairment.

Implications of the Research for Practice

The purpose of the literature review was to determine the extent to which quantitative and qualitative research affirmed the use of CBT for counseling ethnic minority clients.

The synthesis of primary research has revealed that CBT varies in its effectiveness depending on client type, the nature of the disorder, cultural factors, and duration of the intervention, among others. These findings have implications for the application of culturally adapted CBT in clinical practice.

In recent years, CBT has gained acceptance as the best counseling approach for ethnic minority clients. The quantitative studies (RCTs) reviewed support the use of CBT adaptations to treat depression, psychosis, anxiety disorders, binge eating, and trauma among Latino, African American, American Indians, and Asian Americans.

Qualitative research also corroborates the application of CBT in counseling ethnic minorities. The evaluation of CBT adaptations indicates that the efficacy of cognitive-behavioral therapy depends on how well it incorporates the cultural contexts, values, and preferences of the clients.

These findings have many applications in practice. The finding that the efficacy of CBT depends on how it appeals to cultural and personal factors of the client implies that the treatment of ethnic minorities should be individualized.

Cultural considerations should be incorporated into CBT techniques to create an individualized intervention that can improve the outcomes of the clients. CBT interventions modeled around Western cultural values may not be effective when applied to minority immigrant communities.

In particular, the structuring of therapeutic relationships and interaction approaches should reflect the culture and preferences of the client to achieve positive treatment outcomes.

The review indicates that ethnic minority groups benefit significantly from culturally adapted CBT. However, its efficacy is affected by factors such as the patient’s expectations and preferences, the program’s cultural responsiveness, and the cultural competence of the therapist.

Therefore, culturally sensitive CBT programs can be useful in counseling ethnic minorities with psychosis, depression, and anxiety, among others. These approaches are particularly important because ethnic minorities are underrepresented in the psychotherapy field.

This implies that Western perspectives are predominant in the CBT field such that some of the underlying philosophies are incompatible with certain cultural aspects of the minority groups. Thus, in practice, the perspectives of minority clients should be considered to improve the therapeutic outcomes.

From the review, it is evident that the efficacy of CBT depends, in part, on the cultural competency of the counselors. An awareness of the client’s cultural background and values can help counselors support culturally sensitive CBT interventions adapted for minority clients. This has implications for counseling training and curriculum.

Counseling programs that train students on culturally adapted psychotherapy interventions can enhance their understanding of the specific needs of ethnic minority clients.

The use of culturally adapted CBT has empirical support. The review provides qualitative and quantitative evidence for the use of CBT in the treatment of multiple disorders. This has implications for evidence-based practice (EBP) in psychotherapy. The evidence can help in therapeutic decision-making.

Thus, evidence-based CBT can help counselors in selecting the best CBT adaptation that can maximize the outcomes of a particular minority group.

The review also underscores the need for integrating culture into counseling strategies.

The minorities examined in the studies that benefitted from culturally sensitive CBT include Chinese, Latinos, and African Americans, among others. If cultural factors are not integrated into the development and implementation of counseling interventions for minority clients, their dropout rate will increase.

Additionally, a less culturally sensitive approach can prevent them from seeking counseling services. To enhance its efficacy, CBT should be structured around the specific cultural values of the clients.

References

Bennett, S., & Babbage, D. (2014). Cultural Adaptation of CBT for Aboriginal Australians. Australian Psychologist, 49(1), 19-28.

Bennett-Levy, J., Wilson, S., Nelson, J., Stirling, J., Ryan, K., Rotumah, D.,…Beales, D. (2014). Can CBT Be Effective for Aboriginal Australians? Perspectives of Aboriginal Practitioners Trained in CBT. Australian Psychologist, 49, 1-7.

Cachelin, F., Shea, M., Phimphasone, P., Wilson, G., Thompson, D., & Striegel, R. (2014). Culturally Adapted Cognitive Behavioral guided Self-help for Binge Eating: a Feasibility Study with Mexican Americans. Cultural Diversity and Ethnic Minority Psychology, 20(3), 449-457.

Duarte-Velez, Y., Bernal, G., & Bonilla, K. (2010). Culturally Adapted Cognitive-Behavior Therapy: Integrating Sexual, Spiritual, and Family Identities in an Evidence-based Treatment of a Depressed Latino Adolescent. Journal of Clinical Psychology, 66(8), 895-906.

Dwight-Johnson, M., Aisenberg, E., Golinelli, D., Hong. S., O’Brien, M., & Ludman, E. (2011). Telephone-based Cognitive-behavioral Therapy for Latino Patients Living in Rural Areas: a Randomized Pilot Study. Psychiatric Service, 62(8), 936–942.

Hwang, W., Wood, J., Lin, K., & Cheung, F. (2006). Cognitive-Behavioral Therapy With Chinese Americans: Research, Theory, and Clinical Practice. Cognitive and Behavioral Practice, 13, 293–303.

Jackson, J., Schmutzer, P., Wenzel, A., & Tyler, J. (2006). Applicability of Cognitive-Behavior Therapy with American Indian individuals. Psychotherapy, 43(4), 506-517.

Rathod, S., Kington, D., Phiri, P., & Gobbi, M. (2010). Developing Culturally Sensitive Cognitive Behaviour Therapy for Psychosis for Ethnic Minority Patients by Exploration and Incorporation of Service Users’ and Health Professionals’ Views and Opinions. Behavioral and Cognitive Psychotherapy, 38, 511-533.

Rathod, S., Phiri, P., Harris, S., Underwood, C., Thagadur, M., Padmanabi, U. & Kingdon, D. (2013). Cognitive Behaviour Therapy for Psychosis can be Adapted for Minority Ethnic groups: a Randomised Controlled Trial. Schizophrenia Research, 143(2), 319-326.

Saddique, J., Chung, J., Brown, C., & Miranda, J. (2012). Comparative Effectiveness of Medication versus Cognitive-behavioral Therapy in a Randomized Controlled Trial of Low-income Young Minority Women with Depression. Journal of Clinical Psychology, 80(6), 995-1006.

Shen, E., Alden, L., Sochting, I., & Tsang, P. (2006). Clinical Observations of a Cantonese Cognitive-Behavioral Treatment Program for Chinese immigrants. Psychotherapy: Theory, Research, Practice, Training, 43(4), 518-530.

Strasser, A. (2015). Trauma-focused Cognitive Behavioral Therapy: An Evidence Based Practice Applicable with Minority Children. Chronicles of Psychology, 3(1), 11-19.

Webb, M., de Ybarra, D., Baker, E., Reis, I., & Carey, M. (2010). Cognitive-behavioral Therapy to Promote Smoking Cessation among African American Smokers: a Randomized Clinical Trial. Journal of Consulting Clinical Psychology, 78(1), 24-33.

Weiss, B., Singh, S., & Hope, D. (2011). Cognitive-Behavioral Therapy for Immigrants Presenting with Social Anxiety Disorder: Two Case Studies. Clinical Case Studies, 10(4), 324-334.

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