Lorraine T. Benuto Frances R. Gonzalez Jonathan Singer Editors

Lorraine T. Benuto Frances R. Gonzalez Jonathan Singer Editors Handbook of Cultural Factors in Behavioral Health A Guide for the Helping Professional Handbook of Cultural Factors in Behavioral Health Lorraine T. Benuto Frances R. Gonzalez Jonathan Singer Editors

Handbook of Cultural Factors in Behavioral Health

A Guide for the Helping Professional Editors Lorraine T. Benuto Frances R. Gonzalez Department of Psychology Department of Psychology University of Nevada, Reno University of Nevada, Reno Reno, NV, USA Reno, NV, USA

Jonathan Singer Department of Psychology University of Nevada, Reno Reno, NV, USA

ISBN 978-3-030-32228-1 ISBN 978-3-030-32229-8 (eBook) https://doi.org/10.1007/978-3-030-32229-8

© Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland I would like to dedicate this book to the inaugural DICE lab members: Frances, Rory, and Jena for their passion, excitement, kindness, and hard work. They embody all that a clinical psychologist should. By Lorraine T. Benuto

A mi papá, gracias por tus sacrificios, apoyo, y amor. You are my greatest teacher. A mi mamá, que sigues cuidando de mí. To my best friend, Robert, and the rest of my family for your support. To Lorraine, my mentor and hada madrina. By Frances R. Gonzalez

I would like to dedicate this book to my primary mentor and advisor Dr. Tony Papa and my professional and clinical mentor Dr. Amy Hughes Lansing. Dr. Tony Papa has pushed me to be a better researcher, writer, and most importantly, a better person. Dr. Hughes Lansing has guided my professional development and pushed me to be a better clinician, understanding how to be culturally competent and aware of my own biases in order to improve my diverse clients’ lives. L’Chaim!!! By Jonathan Singer Contents

1 Cultural Factors in Behavioral Health: Training, Practice, and Future Directions �� 1 Lorraine T. Benuto, Jonathan Singer, and Frances R. Gonzalez 2 The Elusive Construct of Cultural Competence �� 11 Melissa Tehee, Devon Isaacs, and Melanie M. Domenech Rodríguez 3 Ethical Guidelines for Working with Culturally Diverse Clients �� 25 Roberto Rentería, Amber Schaefer, and Cristalís Capielo Rosario 4 Epidemiological Considerations Working with Culturally Diverse Populations �� 39 Deidre M. Anglin, Rachel Tayler, and Rona Tarazi 5 Using Empirically Supported Assessments with Cultural Minority Clients: Are They Effective? �� 53 Ahmed Fasfous, Julia C. Daugherty, and Antonio E. Puente 6 Cultural Considerations in Psychological Assessment and Evaluation �� 63 Brian D. Leany 7 Cultural Considerations in the Context of Establishing Rapport: A Contextual Behavioral View on Common Factors �� 75 Joanne Qinaʻau and Akihiko Masuda 8 Friend or Foe: Empirically Supported Treatments for Culturally Minority Clients �� 93 Silvia Alves Nishioka, Cindy Y. Huang, and Nolan Zane 9 Behavioral Health Service Delivery with African Americans �� 111 Monnica T. Williams, Jamilah R. George, and Destiny M. B. Printz 10 Behavioral Health Service Delivery with Asian Americans �� 131 Gordon C. Nagayama Hall and Ellen R. Huang

vii viii Contents

11 Behavioral Health Service Delivery with Pacific Islanders �� 143 Lisa A. Duke and Hikianaliʻa Foster 12 Behavioral Health Service Delivery with Latinos �� 163 Ana J. Bridges and Aubrey R. Dueweke 13 Cultural Considerations in Behavioral Health Service Delivery with LGBT Populations �� 177 Frances R. Gonzalez 14 Behavioral Health and Muslim Clients: Considerations for Achieving Positive Outcomes �� 185 Cory E. Stanton 15 Behavioral Health Service Delivery with Immigrants �� 197 Gabriela Hurtado, Laurie Cook Heffron, and Josephine V. Serrata 16 Behavioral Health Service Delivery Among Persons with Disabilities �� 211 Susan Stuntzner and Jacquelyn A. Dalton 17 Culturally Responsive Assessment and Treatment of Generalized Anxiety Disorder �� 231 Jessica R. Graham-LoPresti, Tahirah Abdullah, and Amber Calloway 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview �� 247 Aileen Torres, Sumithra Raghavan, and A. Keshani Perera 19 Cultural Considerations in Behavioral Health Service Delivery for Social Anxiety �� 271 Frances R. Gonzalez 20 Cultural Considerations When Treating Anxiety Disorders with Mindfulness-Based Interventions �� 277 Holly Hazlett-Stevens 21 Obsessive-Compulsive and Related Disorders �� 293 Elisabeth Cordell and Robert Holaway 22 Cultural Considerations in Treating Depression �� 309 Esteban V. Cardemil, Néstor Noyola, and Emily He 23 Cultural Considerations and Sleep �� 323 Ruth Gentry 24 Eating Disorders �� 331 Kimberly Yu and Marisol Perez 25 Cultural Considerations in the Treatment of Sexual Dysfunction �� 345 Rory T. Newlands, Janet Brito, and Dominic M. Denning Contents ix

26 Cultural Considerations for Schizophrenia Spectrum Disorders Part I: Symptoms, Diagnosis, and Prevalence �� 363 Julia E. Maietta, Nina B. Paul, and Daniel N. Allen 27 Cultural Considerations for Schizophrenia Spectrum Disorders II: Assessment and Treatment �� 381 Nina B. Paul, Julia E. Maietta, and Daniel N. Allen 28 Cultural Considerations in the Behavioral Assessment and Treatment of Substance-Related Disorders �� 403 Nina B. Paul, Lance A. Lopez, Michelle N. Strong, and Bradley Donohue 29 Behavioral Problems in Children �� 419 Natalie Bennett and A. Paige Blankenship 30 Cultural Considerations in the Context of Romantic Relationships �� 431 Kristin M. Lindahl and Sara Wigderson Index �� 447 Cultural Factors in Behavioral Health: Training, Practice, 1 and Future Directions

Lorraine T. Benuto, Jonathan Singer, and Frances R. Gonzalez

Cultural Factors in Behavioral define cultural competency as consisting of Health: Training, Practice, knowledge/awareness and skills (Benuto, Casas, and Future Directions & O’Donohue, 2018). Benuto and colleagues highlighted that given the diverse nature of the Across the behavioral health field there is an USA, psychologists must develop a sophisticated urgency to employ cultural considerations into level of knowledge regarding cultures and sub- professional practice. As such American cultures. Indeed, given the rapid diversification Psychological Association (APA, 2002) revised of the USA, there is a need for guidelines for their standards to require that psychologists be working with diverse clients. This book attempts aware of and respect the cultural characteristics of to fulfill this need. their clients. These cultural characteristics include This book is designed for clinicians who work age, gender, ethnicity, race, religion, and other cul- with culturally diverse clients, for scholars who tural factors. Additionally, the APA called for psy- write about and research this area, and for students chologists to be aware of any biases and prejudice who are learning about how cultural factors are they may hold (APA, 2002). Since then, much has relevant to the helping profession. In the USA, been written about cultural competency. minority ethnic groups are growing substantially, Cultural competency is commonly defined with 28% of the US population identifying as using a three-dimensional model (Sue et al., races other than White (Colby & Ortman, (2014). 2009). This model consists of a therapist’s cul- Additionally, approximately 65 million people in tural awareness and beliefs; knowledge of a cli- America speak a foreign language that is not ent’s cultural background, worldview, and English, with over 25 million people having lim- therapy expectations; and the development of ited English language proficiency (Camarota & culturally competent skills (Sue et al., 1982; Sue, Ziegler, 2014). Further, racial and ethnic minority Arredondo, & McDavis, 1992; Sue, Zane, individuals are also more harshly impacted by Nagayama Hall, & Berger, 2009). A recent study untreated mental health issues, resulting in poorer sought to further develop the definition of cul- overall health and productivity (US Department of tural competency and found that psychologists Health and Human Services, 2002). With a diverse pool of clients, helping professionals must be prepared to work with diverse clients. Having the L. T. Benuto (*) · J. Singer · F. R. Gonzalez knowledge and capacity to deliver therapy to Department of Psychology, University of Nevada, Reno, Reno, NV, USA diverse clients will undoubtedly create better cli- e-mail: [email protected] ent-therapist relationships and produce positive

© Springer Nature Switzerland AG 2020 1 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_1 2 L. T. Benuto et al. clinical outcomes. This book aims to provide clini- As described above, this introductory chapter cians with easy to access resources/tools that will includes a section on limitations across the extant assist them working with diverse clients. literature on behavioral health. Finally, in this This book is organized in three sections: a chapter we also attempt to summarize why cul- general section that includes chapters on defin- turally sensitive clinical practices are necessary ing relevant concepts (i.e., cultural competency), and we provide a discussion on training cultur- ethical and epidemiological considerations when ally competent practitioners. working with culturally diverse clients, assessment practices for working with diverse clients, cultural considerations in using empirically sup- Guidelines for Cultural Competence ported treatments, and common factors as they and Training relate to working with diverse clients. The second section includes a series of chapters on According to the American Psychological working with specific cultural groups. There are Association (APA, 2017) code of ethics psychol- two points that must be made with regard to the ogists must be aware of and respect cultural, indi- second section of this book. First, we absolutely vidual, and role differences. Cultural, individual, recognize that within group differences exist and and role differences are defined as consisting of that practitioners will encounter clients who age, gender, gender identify, race, ethnicity, cul- have multiple cultural identities. The extant ture, national origin, religion, sexual orientation, research has highlighted how variables such as disability, language, and socioeconomic status. acculturation and immigration status are impor- Per the APA an understanding of the factors asso- tant variables to consider with regard to client ciated with these cultural variables is essential for outcomes (Benuto & Bennett, 2015; Casas, effective implementation of research and psy- Benuto, & Newlands, 2019; Gonzalez, Benuto, chologists should have or obtain the training nec- & Casas, 2018) and in the context of clinical ser- essary to ensure the delivery of competent vice delivery (Benuto, O’Donohue, Bennett, & services. The code also recognizes that psycholo- Casas, 2019; Benuto & Bennett, 2019). Thus, gists who plan to provide services or conduct while the chapters in Section two of this book research involving populations new to them are intended to provide an overview of cultural undertake training. Similarly, the American considerations for major cultural groups in the Counseling Association (2014) indicates that USA, readers are encouraged to consider how counselors must select and use with caution other cultural variables may intersect with those assessment techniques normed on populations covered in individual chapters in this book. other than that of the client and recognize the Second, readers may notice absent chapters—it effects of cultural variables on test administration is noteworthy that we struggled to find authors to and interpretation. Counselors are also called to write chapters on cultural considerations for key be aware of and address the role of multicultural- cultural groups in the USA (e.g., Native ism and diversity in the supervisory relationship. Americans). Our review of the extant literature yielded some insight into why we struggled to The Status of Training Culturally Competent find authors for certain chapters—there is lim- Practitioners In an attempt to obtain an ited behavioral health research on certain cul- improved understanding of the training litera- tural groups. To mitigate this, we included a ture, Benuto et al. (2018) screened 1230 records section in this chapter on limitations across the and through this process identified 17 training extant literature on behavioral health. The last outcome studies that met their inclusion criteria section of this book includes a series of chapters (i.e., the study empirically examined cultural on presenting problems that practitioners are competency training outcomes with clinical or likely to encounter (e.g., anxiety, chronic pain, counseling psychologists and/or trainees in the sleep disorders, relationship problems etc.). USA or Canada). Results from their systematic 1 Cultural Factors in Behavioral Health: Training, Practice, and Future Directions 3 review revealed that trainings tended to include Cultural adaptations are defined as “modifica- lectures, discussion, case scenarios, cultural tions to existing treatments in ways that make immersion, role-play, contact with diverse indi- them more culturally relevant and attractive to viduals, self-reflection, journaling, and service individuals from particular cultural groups” learning. Typical topics covered included dis- (Cardemil, 2010). Such adaptations should only crimination, worldviews, cultural identity, gen- be employed after an analysis indicates that the eral concepts about culture, and biases. In terms treatment would be less effective without any of outcomes the results across studies supported adaptations, as indicated by finding no cultural that cultural competency training increased group differences in a clinical trial. knowledge but the changes in attitudes and There are two different forms of cultural awareness were not consistent across studies. adaptations, superficial and core. A superficial The authors proposed the development of evi- adaptation is a minimal modification that pre- dence-based training guidelines. serves majority of the fundamental aspects of the intervention. In opposition, a core adaptation Directions for Training Culturally Competent focuses more on the cultural aspects of the Practitioners Subsequently Benuto, Singer, diverse individual and considers how to adapt Newlands, and Casas (2019) conducted a mixed the intervention more vastly to be more applica- methods study where they interviewed and then ble to their lives. Within therapeutic practice, surveyed psychologists in an attempt to develop an cultural adaptations can be made to revise pro- updated overview of the cultural competency gram structure or content, delivery of the inter- training experiences of psychologists. Results vention, or therapist behavior. Research has from this study indicated that the majority of psy- demonstrated that such adaptations yield posi- chologists obtain training via a course in diversity, tive treatment outcomes (Zlotnick, Miller, supervised clinical experience with diverse popu- Pearlsein, Howard, & Sweeney, 2006). However, lations, and didactic training about cultural com- it is difficult to compare treatment outcomes for petency. In general psychologists reported high culturally adapted interventions to standard satisfaction with their training and supervision was interventions. Cardemil (2010) suggested that the greatest predictor of satisfaction with training instead researchers focus on differences in experiences. Psychologists also indicated that cul- minority culture individuals’ engagement in tural competency is achieved by the aforemen- each therapy, as ceiling effects, insufficient num- tioned training experiences. They also endorsed ber of ethnic minority participants, and high that training to get clients to engage, didactic train- attrition may act as confounds in studying treating, experiential training, self-reflection, explora- ment outcome differences. tion of personal biases, clinical exposure to diverse Ollendick, Lewis, and Fraire (2010) argued groups, skills-based training, and training that is that instead of adapting treatments based upon a integrated into other (non-culturally specific) client’s culture, level of acculturation should be training experiences. Participants also indicated assessed. One of the most widely accepted defini- that idiographic training was needed. tions of acculturation refers to the phenomena which occurs when two or more cultural groups come in contact with each other, as well as the Cultural Adaptions as a Mechanism cultural and psychological changes that follow to Improve Outcomes for Diverse (Berry, 2005). Those who are highly acculturated Clients assimilate the newer culture, thus Ollendick, Lewis, and Fraire (2010) argue that adaptations One method of revising treatments to better serve based upon those individuals’ original culture are diverse clients and to increase the number of not necessary. Instead, treatment should only be minority culture individuals seeking behavioral culturally adapted for clients who are less health services is to employ cultural adaptations. acculturated, as they are most likely to identify 4 L. T. Benuto et al. with their original culture’s values and beliefs. Limitations in the Extant Literature Notwithstanding, cultural adaptations, whether on Cultural Competency based upon culture or level of acculturation, are hypothesized to increase minority culture indi- There is a large amount of research on cultural viduals’ willingness and satisfaction with utiliz- competency, which are covered in this book, but ing mental health services. there are certain populations in which research is limited. Despite the paucity of research in these Alternatives to Cultural Adaptations Aside areas, it is essential to describe the extant litera- from cultural adaptations, there are other ture on these populations. Therefore, this con- mechanisms to engage in culturally sensitive cluding chapter will describe cultural competency service delivery. La Roche and Maxie (2003) with family caregiver clients, Native American asserted that specific considerations should be clients, and Jewish clients. These three popula- made prior to deciding to address a client’s cul- tions comprise significant portions of the US ture in therapy. For example, they suggested population and an exploration of the extant litera- that level of emotional distress should be ture provides a greater understanding of cultural assessed, as an individual with an acute psy- competency for clinicians who work with these chological issue would benefit more from hav- populations. ing their more immediate concerns addressed. La Rocher and Maxie (2003) also argued that Cultural Considerations When Working with addressing cultural differences may damage Family Caregivers More than 5.5 million indi- the therapeutic process when such differences viduals are caring for family caregivers with ter- are addressed as “problems” or “deficits.” minal illnesses (Friedman, Shih, Langa, & Instead, behavioral healthcare providers should Hurd, 2015); however, the exact prevalence of first address cultural similarities, then proceed mental health conditions for this population is to frame the discussion in terms of how also unknown though researchers have hypothesized addressing cultural differences benefits the that it is quite high (e.g., Karel, Gatz, & Smyer, therapeutic process. This process of addressing 2012). However, the best practices for mental cultural differences makes treatment more health treatment for family caregivers remain client-centered, which in turn may yield higher unknown. Research has shown that clinicians client satisfaction. play an important role in mitigating mental health conditions using psychoeducation regard- Horin, Hernandez, and Donoso (2012) offered ing end of life (e.g., Chi, Demiris, Lewis, another possible pathway for making psycho- Walker, & Langer, 2016), reducing burden logical services more culturally sensitive, includ- through mindfulness (e.g., Hazlett-Stevens, ing considering a client’s race/ethnicity when Singer, & Chong, 2019), and reducing grief selecting, administering, and interpreting assess- through behavior activation (Papa, Sewell, ment tools. This entails, but is not limited to, Garrison-Diehn, & Rummel, 2013). understanding biases in assessment tools and providing tools in an alternative language. Due to the high rates of burden of caregiving Indeed, the lead editor (and first author of this that has been shown to lead to mental health con- chapter) has published a series of books cultural ditions, clinicians can assuage burden and worry considerations in assessment and psychological for family caregivers by having the knowledge of evaluation (see Benuto, 2013; Benuto & Leany, palliative, long-term, and end-of-life care. Qualls 2015; Benuto, Thaler, & Leany, 2014). Readers and Smyer (2008) stated that clinicians should are encouraged to review these works as well as evaluate a range of clinical and legal capacities the chapters on assessment in the current for and, given the increasing rates of clinicians work- additional guidelines culturally sensitive assessing with older adults and their families, should ment practices. plan ahead and mediate conflicts related to 1 Cultural Factors in Behavioral Health: Training, Practice, and Future Directions 5

financial, residential, health care, and other long- There are mental health conditions that are term-planning dilemmas. Importantly, given the more common for family caregivers of individ- stake family members have in patient outcomes, uals of terminal illnesses, but no literature to mental health treatment for family caregivers our knowledge has shown treatment for these may involve family therapy. This could include prognoses. Pre-loss grief (PLG) is a health con- therapy with the family members of individuals dition that mostly occurs in family caregivers, with the terminal illness to intervene in or prevent yet little is known about the etiology, preva- conflict surrounding caregiving duties. For exam- lence, or treatment. PLG is defined as the pres- ple, a recent review found that the use of mindful- ence of grief symptoms (e.g., yearning/longing ness (Hazlett-Stevens et al., 2019) treatment for for the person) before the individual with the both the family member and the individual with terminal illness has passed away (Nielsen, dementia can reduce mental health symptoms for Neergaard, Jensen, Bro, & Guldin, 2016). There both individuals. is no research regarding treatment of PLG, but There have been numerous studies (e.g., there is research that has addressed grief symp- Hazlett-Stevens et al., 2019; Parsons, Crane, toms. Papa, Sewell, Garrison-Diehn, and Parsons, Fjorback, & Kuyken, 2017) that have Rummel (2013) investigated the feasibility of shown the positive effects of mindfulness-based using behavioral activation (BA) to treat grief stress reduction (MBSR) and mindfulness- symptoms in family members. Their random- based cognitive therapy (MBCT). These posi- ized control trial found that, of the individuals tive effects include but are not limited to, a who finished the treatment, there was a signifi- reduction in chronic pain, anxiety, and depres- cant reduction in grief symptoms, depressive sion. However, until recently, MBSR and MBCT symptoms, and post-traumatic stress disorder have not been examined for family caregivers or symptoms in bereaved family members. Even individuals with dementia. Hazlett-Stevens though BA has not been assessed as an inter- et al. (2019) conducted a literature review of vention for PLG specifically, research has randomized control trials that assessed MBSR shown that BA can reduce grief, depressive, and MBCT for family caregivers of individuals and PTSD symptoms. Therefore, clinicians with terminal illnesses. Nine articles were iden- may use BA with family caregivers who are tified, which found MBSR to be an effective experiencing these symptoms as it may be a treatment in reducing sleep problems, chronic fruitful intervention for PLG. insomnia, chronic lower back pain, worry, anxi- Even though there is a limited amount of ety, and depression. Two studies included fam- research regarding treatment for addressing ily caregivers and individuals with dementia, family caregivers’ mental health conditions, which resulted in the slowing of the cognitive there is research in similar fields that can possi- impairment for the individuals with dementia. bly help guide the treatment of this population. MBCT was found in one article to be effective This can include clinicians having a greater in reducing anxiety symptoms in family care- understanding of resources for family caregiver givers. Despite the paucity of literature examin- that can reduce burden (e.g., palliative care ing evidence-based treatments for family options). Second, it appears that there is a small caregivers, MBSR and MBCT may be valuable amount of research that supports the use of to reduce common symptoms of worry, depres- MBSR and MBCT in family caregivers. This sion, and anxiety. Given the promising results of research provides a foundation and future the limited research, these therapies could help research needs to address if MBSR or MBCT not only the family caregivers, but the individ- are the most effective treatments for this popula- ual with the chronic illness both indirectly tion. Lastly, PLG may occur at a high rate for through an improvement in quality of life for family caregivers. Therefore, determining an family members and also directly if they too effective treatment for PLG can reduce a signifi- participate in the intervention. cant mental health condition for this population. 6 L. T. Benuto et al.

It appears from the research on pathological Cultural Considerations When Working with grief, that BA may be a viable option for this Jewish Clients Judaism is one of the oldest reli- population. More research is needed in this area gions in the world, yet little is known about the to find the most effective treatment for family intersection between Judaism and the therapeutic caregivers with a range of mental health process. There are several possible reasons for conditions. the paucity of research in this area. First, Judaism is subdivided into various groups, each having Cultural Considerations When Working different ideologies, norms, stigmas, and differ- with Native Americans A meta-analysis by ent interpretations of the old testament (Gabbay, Hall, Ibaraki, Huang, Marti, and Stice (2016) McCarthy, & Fins, 2017). Second, Jewish values examined literature that addressed culturally may already play a prominent role in psychology responsive treatment. There were 78 studies as many of the founding fathers of psychology that were examined, none of which focused on (e.g., Schultz & Schultz, 2015) were Jewish Native Americans and it was reported only 1% themselves and brought those values to their of all participants in these studies were Native work. Research on cultural competency and Americans. Therefore, this meta-analysis did Judaism has focused on ultra-Orthodox Jewish not analyze cultural competency for clinicians patients. However, to complicate the research working with Native Americans. This lack of with this population further, ultra-Orthodox is representation of Native Americans in samples further divided into the Hasidim (followers of an has also been demonstrated by a more recent eighteenth-century pietistic movement), the meta-analysis (Soto, Smith, Griner, Domenech Misnagdim (‘opponents’ of the Hasidim), as well Rodríguez, & Bernal, 2018), which found that as other “ultra” religious Jews from Ashkenazi across all the articles examined, only 5% of and Sephardi backgrounds. Research does not participants were Native Americans and there parse between these groups when examining was no conclusion made regarding cultural them in regard to cultural competency, so these competency with this population. There are may not generalize to all ultra-Orthodox Jews. many possible explanations of why research examining clinicians’ competency with work- Research on ultra-Orthodox Jews has focused ing with Native Americans is lacking. First, on the factors that could challenge therapy for Native Americans seek therapy at some of the this population. These include societal stigma, lowest rates (Wang & Kim, 2010), which could fear of the influence of secular ideas, the need for lead to researchers own biased belief that rabbinic approval of the method and provider, examining cultural competency with this popu- and the notion that excessive concern with the lation is not needed. Second, research has self is counter-productive to religious growth shown that large enough sample sizes to detect (Bloch, Gabbay, Knowlton, & Fins, 2018). There effect sizes are difficult to acquire (Whitesell, are treatment modalities that could, theoretically, Sarche, Keane, Mousseau, & Kaufman, 2018) have a positive impact on these patients, if a clini- due to reservations not being open to research- cian’s case conceptualization addresses both the ers. This intricacy in recruitment strategy could hardships Jewish individuals face in combination deter researchers from examining cultural dif- with the mental health condition. This may ferences. However, even though Native include some form of Acceptance and Americans have historically sought therapy at Commitment Therapy (ACT; Hayes, Masuda, low rates, stigma of therapy has decreased in Bissett, Luoma, & Guerrero, 2004) built into the recent years (Schnyder, Panczak, Groth, & treatment plan. For example, ACT might help Schultze-Lutter, 2017). Therefore, research Jewish clients overcome these hardships by should begin examining cultural differences learning to accept their current circumstances that would be salient to improving Native and struggles without invalidating their personal Americans outcomes in therapy. connection with their Jewish values. By shifting 1 Cultural Factors in Behavioral Health: Training, Practice, and Future Directions 7 clients’ urge to fight with or avoid their discom- chapter (and this book) illustrate that there fort, or to change their values to meet societal remains much work to be done—there are areas norms, Jewish clients might benefit from ACT as in which minimal research has been conducted demonstrated in other populations (e.g., Hayes and within the research that has been done, there et al., 2004). is room for methodological improvements. To our knowledge, there are no studies that Finally, readers of this book are encouraged to have examined treatment modalities with ortho- remain cognizant of how each individual will dox Jews, and Schnall (2006) stated that there are present with multiple cultural layers and it is up no treatment studies examining psychotherapy to the practitioner to utilize the intake and with any Jewish ethnic division. Due to the lack assessment process to disentangle which cul- of treatment studies with this population, best tural factors have relevance to the presenting practice for working with Jewish clients and their concern and how to effectively integrate them additional hardships is strictly theoretical. This is into the services provided. We hope that this problematic, as the Jewish population represents book will assist with this process. more than six million Americans (Dashefsky, 2019) and a lack of cultural competency for this population could lead to negative outcomes for References millions of individuals. American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. Available Conclusions from the APA Web site: http://www.apa.org/ethics/ code2002.html As evidenced in this chapter (and across the American Counseling Association (2014). ACA 2014 chapters in this book), there is a significant need Code of Ethics. Retrieved from https://www.counseling.org/docs/default-source/ethics/2014-codeof-eth- for the employment of cultural considerations in ics.pdf?sfvrsn=2d58522c_4 the context of service delivery. While the verdict American Psychological Association. (2017). Ethical on the degree to which such considerations will principles of psychologists and code of conduct. yield improved outcomes (superior to treatment Retrieved from: https://www.apa.org/ethics/code/ethics-code-2017.pdf as usual) for clients is still out (Benuto & Benuto, L. (Ed.). (2013). Guide to psychological assess- O’Donohue, 2015), the chapters within this ment with Hispanics. New York, NY: Springer. book provide a compelling discussion on how Benuto, L., & Bennett, N. (2015). Using prolonged cultural factors may intersect with behavioral exposure therapy to treat post-traumatic stress disorder in a Latina female with a complex trauma health. This coupled with the rapid diversifica- history. International Journal of Psychology and tion of the USA highlights and the APA’s man- Psychological Therapy, 15(1), 143–153. dates for culturally competent service delivery Benuto, L., & Bennett, N. (2019). Written exposure highlights the need for an easy to access therapy: The case for Latinos. Clinical Case Studies. https://doi.org/10.1177/1534650119834359 resources/tools that will assist practitioners in Benuto, L. T., Casas, J., & O’Donohue, W. T. (2018). their work with diverse clients. This book Training culturally competent psychologists: A sys- attempts to fill that need. As illustrated within tematic review of the training outcome literature. this chapter, practitioners should ensure that Training & Education in Professional Psychology, 12(3), 125–134. https://doi-org.unr.idm.oclc. they have received culturally competent train- org/10.1037/tep0000190 ing. Part of this training may include an under- Benuto, L., & Leany, B. (Eds.). (2015). Guide to psy- standing of how cultural adaptations may chological assessment with African Americans. improve outcomes for diverse clients. While not New York, NY: Springer. Benuto, L., & O’Donohue, W. (2015). Is culturally all clients will benefit from cultural adaptions, sensitive cognitive behavioral therapy an empiri- practitioners want to ensure that they have an cally supported treatment?: The case for Hispanics. understanding of when culturally adapting an International Journal of Psychology and Psychological intervention may be warranted. Certainly, this Therapy, 15(3), 405–421. 8 L. T. Benuto et al.

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Counseling and Development, 20, 64–89. https://doi. ment to mental health, a report of the surgeon general org/10.1002/j.2161-1912.1992.tb00563.x (Vol. 2). Rockville, MD: U.S. Department of Health Sue, D. W., Bernier, J. E., Durran, A., Feinberg, L., and Human Services. Pedersen, P., Smith, E. J., & Vasquez Nuttall, E. Wang, S., & Kim, B. S. (2010). Therapist multicultural (1982). Position paper: Cross-cultural counseling competence, Asian American participants’ cultural competencies. The Counseling Psychologist, 10(2), values, and counseling process. Journal of Counseling 45–52. Psychology, 57, 394. Sue, S., Zane, N., Nagayama Hall, G. C., & Berger, L. Whitesell, N. R., Sarche, M., Keane, E., Mousseau, A. C., K. (2009). The case for cultural competency in psy- & Kaufman, C. E. (2018). Advancing scientific meth- chotherapeutic interventions. Annual review of ods in community and cultural context to promote psychology, 60, 525–548. doi:10.1146/annurev. health equity: Lessons from intervention outcomes psych.60.110707.163651 research with American Indian and Alaska native com- Sue, S., Zane, N., Nagayama Hall, G. C., & Berger, munities. American Journal of Evaluation, 39, 42–57. L. K. (2009). The case for cultural competency in Zlotnick, C., Johnson, D. M., & Kohn, R. (2006). Intimate psychotherapeutic interventions. Annual Review of partner violence and long-term psychosocial function- Psychology, 60, 525–548. ing in a national sample of American women. Journal U.S. Department of Health and Human Services. (2002). of Interpersonal Violence, 21(2), 262–275. Mental health: Culture, race and ethnicity, a supple- The Elusive Construct of Cultural Competence 2

Melissa Tehee, Devon Isaacs, and Melanie M. Domenech Rodríguez

The origins of cultural competence as a con- In the decades following, there has been much struct are unclear. We have evidence as far back support for the concept of cultural competence as 1927 of discussions regarding race and cul- (Gallardo, Parham, Trimble, & Yeh, 2012) espe- ture in psychology. Klineberg’s (1927, 1934) cially related to health care delivery across pioneering work in intelligence testing applied professions (e.g., nursing, social work, debunked myths of racial superiority using sci- psychology, medicine; Kohli, Huber, & Faul, entific data and Kenneth and Mamie Clark’s 2010; Leininger, 1988; Loftin, Hartin, Branson, foundational experiments (Clark & Clark, & Reyes, 2013; National Association of Social 1939) were used to support school desegrega- Workers, 2015). Among academics and practitio- tion in the USA in 1954. In the 1950s, Madeleine ners in cultural competence, there is agreement Leininger began developing a theory of cultural that cultural considerations in treatment ought to care diversity and universality (Leininger, transform practice rather than be an added con- 1988). In 1967, Gordon Paul (1967) famously sideration in practice (Gallardo et al., 2012; asked “What treatment, by whom, is most effec- Leininger, 1988). tive for this individual with that specific prob- Professionals across helping professions lem, and under which set of circumstances,” appear to enthusiastically favor an approach to (p. 111) albeit outside of a discussion of cul- service provision, scholarship, and teaching ture, this question remains deeply relevant to that considers culture and context. How to psychotherapists advancing cultural compe- define cultural competence and practice in tence today. In the 1970s, various conferences accordance to guidelines for the advancement in psychology (Vail, Austin, Dulles confer- of cultural competence, however, appears to be ences) professionals discussed the need for a work in progress. In this chapter, we will integrating multiculturalism into training focus on definitions of cultural competence and (Gamst, Liang, & Der-Karabetian, 2011; Sue associated constructs in the context of helping et al., 1982). The term itself increased in promi- professions. There is much work in other fields nence in the scholarly literature in the 1990s (e.g., education; McAllister & Irvine, 2000; (Saha, Beach, & Cooper, 2008). National Education Association, 2017), however that work is beyond the scope of our discussion. We provide a table with definitions M. Tehee (*) · D. Isaacs advanced across helping professions. We also M. M. Domenech Rodríguez Utah State University, Logan, UT, USA report on efforts to train students and providers e-mail: [email protected] to improve cultural competence.

Definitions of Cultural Competence background than one’s own” (Hadwiger, 1999, p. 47) to a more nuanced set of guidelines based Literature on cultural competence exists in mul- on an ecological approach to cultural compe- tiple fields such as nursing, mental health, medi- tence that reflect “current trends in the literature cine, education, and social work (to name a few) that consider contextual factors and intersection- with definitions and terminology varying from ality among and between reference group identi- discipline to discipline. For example, social work ties, including culture, language, gender, race, was one of the first fields to examine the idea of ethnicity, ability status, sexual orientation, age, “cultural awareness” as an important factor in gender identity, socioeconomic status, religion, service provision (Green, 1982). One of the earli- spirituality, immigration status, education, and est mentions of cultural competence as a frame- employment, among other variables” (American work for informing patient care in nursing is Psychological Association, 2002, 2017). “cultural care theory,” which is a holistic method While social workers, nurses, physicians, and of acknowledging cultural lifeways while provid- counselors may often represent a much needed ing patient services (Leininger, 1988). Leininger “front line,” cultural competence may be extended recognized that interactions between providers throughout service industries as it also pertains to and patients were a process with multiple moving the work of receptionists, administrative staff, parts which required a certain sense of linkage to human resources specialists, and CEOs. The help unify exchanges. notion that organizations must have the ability to In the field of mental health, cultural compe- incorporate cultural competence “in all aspects of tence is generally conceptualized as a tripartite policy making, administration, practice, service model composed of self-awareness, knowledge, delivery and systematically involve consumers, and skills (Sue, Arredondo, & McDavis, 1992). key stakeholders and communities” has become Self-awareness refers to both attitudes that a per- more widely recognized (National Center for son holds about cultural groups other than their Cultural Competence, 1998). Through continued own and awareness of themselves as cultural evolution of these concepts, cultural competence beings. Knowledge refers to specific knowledge has been utilized from a systems perspective with about other cultural groups (e.g., language, tradi- multiple authors acknowledging the need for tions, beliefs). Skills refer to specific interper- application of cultural competence in policy mak- sonal and intervention abilities. This definition is ing and at multiple tiers of service-oriented orga- one of the most frequently cited models in the nizations (Brach & Fraserirector, 2000). Some literature (Bernhard et al., 2015), especially definitions of cultural competence have also within psychology. Cultural competence is also included recognizing systemic forms of oppres- frequently defined as a set of congruent behaviors sion (Schlesinger & Devore, 1995), social justice that extend well beyond tolerance to allow pro- (Krentzman & Townsend, 2008), and health dis- fessionals to work effectively in cross-cultural parities (Capell, Veenstra, & Dean, 2007). settings (Cross, Bazron, Dennis, & Isaacs, 1989; Roberts et al., 1990). While Sue et al.’s (1992) definition focuses on individual’s abilities, Cross Emerging Components of Cultural et al. (1989) focus on a “system of care” that Competence includes individual as well as programs, agencies, and institutions. As the definition of cultural competence has Table 2.1 illustrates the evolution of defini- expanded and become more refined, more terms tions of cultural competence over time. While have been developed. For example, authors often this table is not exhaustive, it is representative emphasize cultural competence as “demon- across helping professions. Existing definitions strated” or an ongoing “lifelong process” where constitute a wide range from “the process of the competent provider acts as a lifelong learner, working with patients from a different cultural able to put cultural competence into action while 2 Cultural Competence 13

Table 2.1 Definitions of cultural competence Author(s)/(Year) Definitions Sue (1982) “Sue defined multicultural counseling competence as an ongoing process that involves counselors’ development of: (1) awareness of their own cultural values, biases, and position in established power structures and the impact of these on relationships with clients, (2) awareness of a client’s world view, and (3) ability to develop and implement culturally appropriate interventions” (as cited in Boyle & Springer, 2001, pp. 55–56) Green (1982) “Green (1982) first defined cultural competence as the ability to conduct professional work in a way that is consistent with the expectations which members of a distinctive culture regard as appropriate among themselves. This definition emphasizes the trained worker’s ability to adapt professional tasks and work styles to the cultural values and preferences of clients” (as cited in Boyle & Springer, 2001, p. 55) Tripp-Reimer and “Culture Brokerage is essentially an act of translation in which messages, instructions and Brink (1985) belief systems are manipulated and processed from one group to another. As a nursing intervention, Culture Brokerage involves the nurse’s acting as a mediator between clients and members of orthodox health professions. Culture Brokerage may be used whenever there are separate culture groups and a need to establish links between them” (p. 352) Leininger (1988) “The cultural care theory is held to be the broadest and most wholistic guide to study human beings with their lifeways, cultural values and beliefs, symbols, material and nonmaterial forms, and living contexts” (p. 155) Cross et al. (1989) “Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations. The word ‘culture’ is used because it implies the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group. The word competence is used because it implies having the capacity to function effectively. A culturally competent system of care acknowledges and incorporates--at all levels--the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally-unique needs” (p. 13) Roberts et al. “A multitude of terms have been used in the field to relate cultural issues to practice. Among (1990) these terms are cultural competence, cultural sensitivity, cultural diversity, cultural relevance and cultural awareness. We have chosen to encourage programs to employ the term ‘cultural competence’ for several reasons. Competence implies more than beliefs, attitudes and tolerance, though it also includes them. Competence also implies skills which help to translate beliefs, attitudes and orientation into action and behavior within the context of daily interaction with families and children” (p. 4) Borkan and Neher Borkan and Neher introduce the Developmental Model of Ethnosensitivity to address issues (1991) that arise in utilizing standard [cross-cultural] curriculum with medical trainees who have “varying capacities both to accept cultural differences and to integrate cross-cultural tools” (p. 212). The model is described as consisting of seven developmental stages: fear, denial, superiority, minimization, relativism, empathy, and integration (p. 213) Sue et al. (1992) “… [cross-cultural counseling competency] characteristics (a) counselor awareness of own assumptions, values, and biases; (b) understanding the worldview of the culturally different client; and (c) developing appropriate intervention strategies and techniques would each be described as having three dimensions: (a) beliefs and attitudes, (b) knowledge, and (c) skills” (p. 481) Schlesinger and “The term ‘ethnic sensitive social work practice’ once introduced came to be used by social Devore (1995) workers when referring in a broad, general sense to practice that is mindful of the effects of ethnic and minority group membership in social functioning and seeks to incorporate this understanding into practice. Used this way, the term is not limited to any single or particular definition or approach” (p. 33) Lavizzo-Mourey “…we conceptualize ‘cultural competence’ as the demonstrated awareness and integration and MacKenzie of three population-specific issues: health-related beliefs and cultural values, disease (1996b) incidence and prevalence, and treatment efficacy. But perhaps the most significant aspect of this concept is the inclusion and integration of three areas that are usually considered separately when they are considered at all” (p. 919) (continued) 14 M. Tehee et al.

Table 2.1 (continued) Author(s)/(Year) Definitions Tervalon and “…cultural competence in clinical practice is best defined not by a discrete endpoint but as a Murray-Garcia commitment and lifelong process that individuals enter into on an ongoing basis with patients, (1998) communities, colleagues, and with themselves (L. Brown, MPH, Oakland health advocate, personal communication, March 18, 1994)” (p. 118) National Center for “Cultural competence requires that organizations: have a defined set of values and Cultural principles, and demonstrate behaviors, attitudes, policies and structures that enable them to Competence (1998) work effectively cross-culturally.” Organizations must “have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of difference, (4) acquire and institutionalize cultural knowledge and (5) adapt to diversity and the cultural contexts of the communities they serve.” Organization must be able to “incorporate the above in all aspects of policy making, administration, practice, service delivery and systematically involve consumers, key stakeholders and communities.” In summary, “cultural competence is a developmental process that evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge and skills along the cultural competence continuum.” (This framework is cited as adapted from Cross et al., 1989). Orlandi (1998) Orlandi suggests that cultural competence is “clearly multidimensional” and that “relevant aspects vary on a continuum from high to low” (p. 297). Orlandi proposes a Cultural Sophistication Matrix consisting of cognitive, affective, and skills dimensions as well as overall effect ranging across categories of culturally incompetent, culturally sensitive, and culturally competent (p. 297) Campinha-Bacote Campinha-Bacote conceptualizes cultural competence as consisting of five interdependent (1999) constructs: (1) cultural awareness, or the “deliberate, cognitive process in which health care providers become appreciative and sensitive to the values, beliefs, lifeways, practices, and problem solving strategies of clients’ cultures”; (2) cultural knowledge, or the “process of seeking and obtaining a sound educational foundation concerning the various world views of different cultures”; (3) cultural skill, which is defined as “the ability to collect relevant cultural data regarding the clients’ health histories and presenting problems as well as accurately performing a culturally specific physical assessment”; (4) cultural encounters, which are a “process which encourages health care providers to engage directly in cross- cultural interactions with clients from culturally diverse backgrounds”; (5) cultural desire, or the “motivation of health care providers to ‘want to’ engage in the process of cultural competence” (pp. 204–205) Resnicow et al. “Cultural competence is the capacity of individuals to exercise interpersonal cultural (1999) sensitivity. Thus, culturally competent refers to practitioners, whereas culturally sensitive relates more to intervention materials and messages” (p. 11) Kim-Godwin, “In the proposed Culturally Competent Community Care (CCCC) model, community-based Clarke, and Barton care is viewed on a continuum from individual-focused health to whole community (2001) population-focused health and health care. Four dimensions of cultural competence are proposed. These dimensions are caring, cultural sensitivity, cultural knowledge, and cultural skills. Cultural competence involves not only caring, but cultural sensitivity, knowledge, and language ability” (p. 919) Sue (2001) “The MDCC [Multiple Dimensions of Cultural Competence] offers a conceptual framework for organizing three primary dimensions of multicultural competence: (a) specific racial/cultural group perspectives, (b) components of cultural competence, and (c) foci of cultural competence” (p. 791). Sue goes on to note the three components of cultural competence: belief/attitude, knowledge, and skill (p. 799) Betancourt, Green, “The field of ‘cultural competence’ in health care has emerged in part to address the factors and Carrillo (2002) that may contribute to racial/ethnic disparities in health care. Cultural competence in health care describes the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs. The ultimate goal is a health care system and workforce that can deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background, or English proficiency” (p. 2) (continued) 2 Cultural Competence 15

Table 2.1 (continued) Author(s)/(Year) Definitions Dunn (2002) “What exactly is cultural competence? One way to answer this question is by stating what it is not. Cultural competence is not something that can be taught in traditional ways. It is not a technical skill that one can master such as learning how to take a blood pressure reading or read an electrocardiogram. It is not a problem-solving skill that one can develop, such as the ability to interpret clinical signs. It is not a communication technique that one can refine, such as ‘active listening’ or ‘use of I messages’. Cultural competence, in fact, requires a fundamental change in the way people think about, understand, and interact with the world around them” (pp. 105–106) Purnell (2002) “Cultural competence is a process, not an endpoint (See figure 1 in Purnell, p. 11). One progresses (a) from unconscious incompetence (not being aware that one is lacking knowledge about another culture), (b) to conscious incompetence (being aware that one is lacking knowledge about another culture), (c) to conscious competence (learning about the client’s culture, verifying generalizations about the client’s culture, and providing culturally specific interventions), and finally (d) to unconscious competence (automatically providing culturally congruent care to clients of diverse cultures)” (p. 9) Shiu-Thornton “Cultural competency is a term most associated with the provision of direct services to (2003) underserved and hard-to reach ethnic, linguistic, or cultural populations. Initially, this was articulated as providing heath or mental health care and services in a manner culturally sensitive or culturally appropriate to ethnic minority populations who faced multiple barriers in accessing and using these services” (p. 1361) Frusti et al. (2003) “Diversity competence is defined as an individual’s ability to respect each person’s uniqueness” (p. 31) Suh (2004) Attributes of cultural competence include ability, openness, and flexibility. Antecedents or elements of cultural competence include the following domains: cognitive (awareness & knowledge), affective (sensitivity), behavioral (skills), and environmental (interaction/ encounter). Outcomes are discussed as “receiver-based variables, provider-based variables, and health outcome variables” (p. 98) Beach et al. (2005) “Cultural competence has been defined as ‘the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences’ (Cooper & Roter, 2002) by recognizing the importance of social and cultural influences on patients, considering how these factors interact, and devising interventions that take these issues into account” (Betancourt, Green, Carrillo, & Ananeh-Firempong II, 2003) Giger et al. (2007) “The first imperative of cultural competence is to be competent in one’s own cultural heritage. After personal understanding comes respect and appreciation for the values and behaviors of others. Knowledge of cultural differences is essential if sensitivity and competence are to occur. Only when self-awareness combines with insight about others then true sensitivity can be demonstrated by individuals, health care systems, and communities” (p. 98) Sue and Sue (2008) “…cultural competence is an active, developmental, and ongoing process and that it is aspirational rather than achieved” (pp. 43–44) Abbe, Gulick, and “Cross-cultural competence refers to the knowledge, skills, and affect/motivation that Herman (2008) enable individuals to adapt effectively in cross-cultural environments. Cross-cultural competence is defined here as an individual capability that contributes to intercultural effectiveness regardless of the particular intersection of cultures” (p. 2) Krentzman and “This study uses a definition of cultural competence drawn from the Sue (1982, 1992) and Townsend (2008) the National Association of Social Workers (2001) models…In brief, both models concur that cultural competence means having the beliefs, knowledge, and skills necessary to work effectively with individuals different from one’s self; that cultural competence includes all forms of difference; and that issues of social justice cannot be overlooked” (p. 8) Fantini (2009) “Stated another way, intercultural competence may be defined as complex abilities that are required to perform effectively and appropriately when interacting with others who are linguistically and culturally different from oneself. Whereas effective reflects the view of one’s own performance in the target language-culture (LC2; i.e., an outsider’s or ‘etic’ view), appropriate reflects how natives perceive such performance (i.e., an insider’s or ‘emic’ view)” (p. 458) Kirmayer (2012) Kirmayer suggests that cultural competence, “needs to be critically assessed and re-thought to identify alternative models and metaphors that may better fit the needs of patients and providers working in specific health care settings across nations, regions and communities” (p. 150) (continued) 16 M. Tehee et al.

Table 2.1 (continued) Author(s)/(Year) Definitions Garneau and Pepin “The constructivist definition of cultural competence proposed in this article is intended to (2015) reflect global trends, not just the majority perspective. Hence, we define cultural competence as follows: A complex know-act grounded in critical reflection and action, which the health care professional draws upon to provide culturally safe, congruent, and effective care in partnership with individuals, families, and communities living health experiences, and which takes into account the social and political dimensions of care” (p. 12) Bustamante, “This construct [intercultural competence] frequently is used as the basis for developing Skidmore, Nelson, measures of attitudes, dispositions, values, beliefs, knowledge, and skills of professionals’ and Jones (2016) approaches to the other or those who differ culturally from themselves. Cultural competence might best be defined as one’s attitudes toward, knowledge about, and skills in interacting appropriately and effectively with diverse groups of people (Fantini, 2009; Sue & Sue, 2007)” (pp. 298–299) American “It is important to note that, for the purposes of the Multicultural Guidelines, cultural Psychological competence does not refer to a process that ends simply because the psychologist is deemed Association (APA) competent. Rather, cultural competence incorporates the role of cultural humility whereby (2017) cultural competence is considered a lifelong process of reflection and commitment (Hook & Watkins, 2015; Waters & Asbill, 2013)” (p. 8) Henderson, Horne, “Many terms and definitions exist in the literature as to the concept and meaning of cultural Hills, and Kendall competence (Fantini, 2009). For example, the National Health and Medical Research (2018) Council, Australia (NHMRC, 2006, p. 7), defines cultural competence as ‘a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency or those professions to work effectively in cross- cultural situations’. In this sense, cultural competence is the capacity of the health system to improve the health of consumers by integrating culture into the delivery of health services” (p. 591) Benuto, Singer, “Cultural competency is best conceptualized as a two-dimensional construct whereby the Casas, González, dimensions of knowledge and awareness are a single dimension” (p. 379) and Ruork (2018) incorporating new skills across multiple settings tailor a specific treatment, often a manual, and situations (Lavizzo-Mourey & Mackenzie, whereas cultural competence refers to the skills 1996a; Tervalon & Murray-Garcia, 1998). of a person. A culturally competent provider may Campinha-Bacote (1999) extended previous look for a cultural adapted treatment manual to views of cultural competence to incorporate “cul- support their intervention efforts. tural encounters” as a necessary component of In reference to the numerous ways in which building on cultural competence skills. cultural competence and other terms from the lit- Campinha-Bacote also added “cultural desire” as erature intersect, some common themes emerge. a means of gauging the investment of the profes- For instance, words such as “consideration,” sional in the competence process. In Table 2.2, “acknowledgement,” and “engagement” are fre- we lay out some existing and emerging terms in quently used across terminologies, denoting that the cultural competence literature. competence regardless of discipline requires both We view the terms in Table 2.2 as emerging a reflective and active component. Certainly, we components of cultural competence and not as cannot learn to be culturally attuned, responsive, separate entities. For example, cultural adapta- or competent without first exploring or consider- tion of evidence-based interventions is related to ing the histories and modern contexts in which an cultural competence but is a distinct construct. individual exists. Language and cultural identities Indeed, a recent meta-analysis provides evidence are key components of this existence continuum, for both in the same manuscript (Soto, Smith, as are ways of knowing, being, and operating in a Griner, Domenech Rodríguez, & Bernal, 2018). given environment (Bernal, Jiménez-Chafey, & Cultural adaptation refers to the efforts made to Domenech Rodríguez, 2009; Hoskins, 1999). As 2 Cultural Competence 17

Table 2.2 Terms in cultural competence literature Term Definition Cultural Cultural adaptation is “the systematic modification of an evidence-based treatment (EBT) or adaptation intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values” (Bernal et al. 2009, p. 362) Cultural A relational process utilized when engaging in an interpersonal exchange and that involves “(a) attunement acknowledging the pain of oppression, (b) engaging in acts of humility, (c) acting with reverence, (d) engaging in mutuality, and (e) maintaining a position of ‘not knowing’.” (Hoskins, 1999, p. 77) Culturally “Refers to programs and messages that combine culture, history, and core values as a medium to based motivate behavior change. Examples include Afrocentric substance use or violence prevention programs or programs for indigenous Americans that focus on ancestral spiritual systems… culturally based interventions, while potentially effective, have the potential to be culturally insensitive”… when it is assumed that “individuals identify with and gravitate toward their racial/ ethnic group psychologically and socially” without checking that assumption (Resnicow et al. 1999, pp. 11–13) Cultural “Cultural humility incorporates a life-long commitment to self-evaluation and self-critique, to humility redressing power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations” (Tervalon & Murray-Garcia, 1998, p. 117) “In a multicultural world where power imbalances exist, cultural humility is a process of openness, self awareness, being egoless, and incorporating self reflection and critique after willingly interacting with diverse individuals. The results of achieving cultural humility are mutual empowerment, respect, partnerships, optimal care, and lifelong learning.” (Foronda, Baptiste, Reinholdt, & Ousman, 2016, p. 213) Cultural humility is “self-reflective, other-oriented, and power-attenuating openness to clients as multicultural beings” (Tormala, Patel, Soukup, & Clarke, 2018, p. 54) Cultural “Social workers need to appreciate the traditions and beliefs of clients from different cultures to responsiveness provide effective services” (Yukl, 1986, p. 223); “It cannot be emphasized enough that the communication of an understanding and appreciation of [American Indian] cultural values is primary in establishing the desired therapeutic alliance with [American Indian] patients” (Yukl, 1986, p. 226) Cultural safety “In New Zealand during the 1980s the concept of cultural safety was born out of the work of a Maori nurse academic, Irihapiti Ramsden to address issues related to health disparities and unsafe interactions between the country’s Indigenous and non-Indigenous peoples. More recently cultural safety has been viewed as a way forward and framework for non-Indigenous health professionals to work in partnership with Indigenous peoples to respond to the adverse impact of colonisation and help address significant health disparities (Williams, Smith, & Sharp, 2016). Cultural safety is underpinned by a social justice framework and requires individuals to undertake a process of personal reflection. Cultural awareness (defined as the beginning step in this process) acknowledges difference and contributes to cultural sensitivity (building on the awareness of difference through cultural acceptance, respect and understanding). Cultural safety is therefore a holistic and shared approach, where all individuals feel safe, can undertake learning together with dignity, and demonstrate deep listening (Ramsden, 2002; Wepa, 2003; Williams et al., 2016)” (Milne, Creedy, & West, 2016, pp. 20–21) Cultural “The extent to which ethnic/cultural characteristics, experiences, norms, values, behavioral sensitivity patterns and beliefs of a target population as well as relevant historical, environmental, and social forces are incorporated in the design, delivery, and evaluation or targeted health promotion materials and programs” (Resnicow et al., 1999, p. 11) Cultural “The process of creating culturally sensitive interventions, often involving the adaptation of tailoring existing materials and programs for racial/ethnic subpopulations” (Resnicow et al., 1999, p. 11) Multicultural/ “Incorporating and appreciating perspectives of multiple race/ethnic groups without assumptions cultural of superiority or inferiority. In this sense, culturally competent individuals and culturally pluralism sensitive interventions are implicitly multicultural” (Resnicow et al., 1999, p. 11) (continued) 18 M. Tehee et al.

Table 2.2 (continued) Term Definition Patient “The primary aim of patient centeredness has been to individualize quality, to complement the centered care healthcare quality movement’s focus on process measures and performance benchmarks with a return to emphasis on personal relationships and ‘customer service’. As such, patient centeredness aims to elevate quality for all patients. The primary aim of the cultural competence movement has been to balance quality, to improve equity and reduce disparities by specifically improving care for people of color and other disadvantaged populations. Because of these different emphases, patient centeredness and cultural competence have targeted different aspects of healthcare delivery. Despite these different focuses, however, there is substantial overlap in how patient centeredness and cultural competence are operationalized, and consequently in what they have the potential to achieve” (Saha et al., 2008, p. 1282) an added layer of complexity, we live in a multi- within their own service frameworks. This is not cultural world and cultures interact. Hence the to discount the importance of these diverging aforementioned components may vary from set- terms. The spirit in which these frameworks ting to setting (e.g., differ from the emergency operate is the same one personified by true cul- room to a therapy session) or manifest quite dif- tural competence wherein providers may hold ferently in the presence of service providers of varied perspectives together to arrive at a more varying demographic characteristics (e.g., a comprehensive understanding. Regardless, a patient seeing a doctor of similar or dissimilar unified definition is certainly lacking despite race, ethnicity, age, sexual identity). “increased attention to understanding,” and The idea of “considering,” while one of the practitioners and researchers generally agree most frequently used descriptors in cultural there is a distinct need for a clearer conceptual- competence frameworks, can be troublesome. ization of cultural competence (Boyle & By way of interpretation, “considering” may Springer, 2001; Roberts et al., 1990; run the gamut from mild curiosity to in-depth Worthington, Soth-McNett, & Moreno, 2007). examination. Likewise, “acknowledgement” is also a multifaceted component that requires personal introspection as to definition. Service pro- Competencies and Benchmarks viders may define acknowledgement as synonymous with recognition, equate the term Cultural competence training has evolved based with tolerance, or define it as acceptance. on the available definitions and conceptualiza- “Engagement” is equally ambiguous—Is the tions. Older publications point to frameworks. engagement process passive or active? Is For example, Cross et al.’s (1989) continuum for “engagement” an agreement or a commitment? understanding a provider or agency’s location on We would posit that the culturally competent the cultural competence spectrum that ranges provider is capable of taking a deeper dive into from culturally destructive to culturally profi- context, of moving beyond simple recognition, cient. For each of the six levels, Cross provides and be able to commit to actively becoming a attitudinal and behavioral descriptors. Sue et al. part of the competence process. Reflection and (1982) provided the first benchmarks for cultural action become mechanisms through which cul- competence from the American Psychological tural competence is conducted and with them Association’s Division 17 Education and Training comes a certain awareness on the part of the ser- Committee for clinicians. Currently, individual vice provider, which maybe unpleasant or even and cultural diversity are considered one of the painful depending on the insights gained. We foundational competencies for psychologists and think this further demonstrates that the terms in the behavioral anchors for the benchmarks Table 2.2 are facets of the same cultural compe- include knowledge of self and others as cultural tence paradigm, each having specific utility beings and applies to interactions, assessment, 2 Cultural Competence 19 treatment, and consultation (Fouad et al., 2009; The importance of cultural competence for help- Hatcher et al., 2013). ing professionals in the field has become more evi- Standards for accreditation for Medical dent with multiple professional organizations Education include cultural competence and adopting and tailoring specific guidelines of cul- health care disparities based on the tripartite tural competence to facilitate education and train- model, including self-awareness, knowledge, and ing of professionals in response to the increasing skills (Liaison Committee on Medical Education, diversity of patients, clients, and students (Boyle 2018). Medical professionals must acknowledge & Springer, 2001; Frusti, Niesen, & Campion, “[t]he manner in which people of diverse cultures 2003). Elements of cultural competence can be and belief systems perceive health and illness and found throughout the American Counseling respond to various symptoms, diseases, and treat- Association’s code of ethics (American Counseling ments” (p. 11) and the standard goes further to Association, 2014) and in many different practice include the need to recognize and address health competencies, such as Competencies for care disparities (Liaison Committee on Medical Counseling the Multiracial Population (Multi- Education, 2018). Medical educators developed Racial/Ethnic Counseling Concerns (MRECC) benchmarks for faculty in medical schools Interest Network of the American Counseling (Sorensen et al., 2017) and evaluated them Association Taskforce & Counseling Association empirically to derive ten critical characteristics Taskforce, 2015), Multicultural and Social Justice of cultural competence needed to effectively train Counseling Competencies (The Multicultural medical students (Hordijk et al., 2019). Counseling Competencies Revisions Committee, In the field of social work, the emphasis on 2015), in addition to competency guidelines for cultural competence is interwoven into many specific populations. Psychology professionals facets of the profession. The Code of Ethics of can look to the Guidelines on Multicultural the National Association of Social Workers Education, Training, Research, Practice, and begins by stating “[t]he primary mission of the Organizational Change (American Psychological social work profession is to enhance human Association, 2017) as well as guidelines for spe- well-being and help meet the basic human needs cific populations, such as Guidelines for of all people, with particular attention to the Psychological Practice With Transgender and needs and empowerment of people who are vul- Gender Nonconforming People (American nerable, oppressed, and living in poverty” Psychological Association, 2015). (National Association of Social Workers, 2017). Principles in the ethics code highlight the importance of diversity and cultural competence Summary and Recommendations is a prominent ethical standard. One of the nine educational accreditation competencies in social Rather than seeing the definition of cultural com- work is to “Engage Diversity and Difference in petence as a moving target, we understand that Practice” (Council on Social Work Education, the definitions of both “culture” and “compe- 2015). The professional practice guidelines in tence” are elusive in nature and, thus, a definition social work further expand the reach of cultural of cultural competence is necessarily a work in competence in that it progress. As we culled through the literature, we also requires advocacy and activism. It is critically see many terms and we welcome them, and we important to provide quality services to those who also know that sometimes narratives are more find themselves marginalized; and it is also essen- directed at replacing rather than enriching bodies tial to disrupt the societal processes that marginal- of scholarship. One of our overarching recom- ize populations. Cultural competence includes action to challenge institutional and structural mendations is for scholars and practitioners to oppression and the accompanying feelings of priv- embrace the complexity of this construct and ilege and internalized oppression (National resist the urge to find a replacement construct Association of Social Workers, 2015, p. 10). with a neat definition but rather incorporate new 20 M. Tehee et al. knowledge and conceptualizations as they arise themselves”(p. 118). Their working definition and celebrate the deeper and broader understand- was similar to Cross et al. (1989): ing that results from added concepts. Becoming culturally competent is a developmental Researchers may feel the most desire to have a process for the individual and for the system. It is working operational definition, especially in con- not something that happens because one reads a sideration of measurement. Existing measures book, or attends a workshop, or happens to be a member of a minority group. It is a process born of are usually based on different components of cul- a commitment to provide quality services to all and tural competence, including the tripartite compo- a willingness to risk. (p. 21) nents (e.g., Revised Multicultural Awareness, Knowledge, & Skills Survey, Counselor Edition: Similarly, Resnicow, Baranowski, Ahluwalia, Kim, Cartwright, Asay, & D’Andrea, 2003; and Braithwaite (1999) clarify that cultural com- Multicultural Counseling Self-Efficacy Scale, petence is the ability to exercise cultural sensitiv- Racial Diversity Form: Sheu & Lent, 2007; Sheu, ity in an interpersonal exchange. The authors Rigali-Oiler, & Lent, 2012). The aforementioned provide an important distinction that cultural scales, as most measures of cultural competence, competence resides in practitioners whereas cul- are practitioner self-report and can serve to facili- tural sensitivity resides in materials and mes- tate self-awareness and reflection. There are also sages. Domenech Rodríguez and Bernal (2012) measures of supervisor ratings of trainees cul- make a similar distinction between cultural com- tural competence (LaFromboise, Coleman, & petence which resides in the practitioner, and cul- Hernandez, 1991), trainees’ and supervisors’ per- tural adaptations, which reside in the treatment spectives of multicultural competence in supervi- manuals. sion (Pope-Davis, Toporek, & Ortega-Villalobos, We do understand the practical concerns that 2003), student ratings of professional programs’ have led to a desire to have an agreed upon defini- training and curriculum in regards to multicul- tion so that interventions may be developed for tural climate (Pope-Davis, Liu, Nevitt, & trainees or helping professionals, which in turn Toporek, 2000), and client perceptions of helping would allow for their test of effectiveness for professionals’ cultural competence (Cornelius, both learning of providers and the outcomes of Booker, Arthur, Reeves, & Morgan, 2004). These those whom they serve. We do believe the litera- measures are not a criterion style measure as ture shows a great deal of diversity in conceptual- there is not a cut-off score and thus one possesses izations, and also points fairly clearly to cultural competence, but these measures allow agreement over the use of the tripartite model of for room to grow in cultural competence. cultural competence as a primary conceptualiza- A criticism of cultural competence is that the tion. For providers that want clear guidance, it term somehow communicated that one is to pos- would be reasonable to proceed with that model sess said competence. In fact, cultural compe- (Sue et al., 1992; Sue, 1998). tence has been operationally defined as a journey, In sum, a great deal of thought and consider- not a destination, from early inceptions (Cross ation has gone into understanding the importance et al., 1989; Sue et al., 1982). When introducing of culture in interpersonal exchanges as they the concept of cultural humility, Tervalon and relate to outcomes in psychotherapy and other Murray-Garcia (1998) did not suggest it as a helping professions. We believe the elusive nature replacement term but rather recommended that of the construct of cultural competence is per- cultural humility might be a more realistic haps due to the very nature of cultural compe- achievement for medical trainees receiving cul- tence as a complex and multi-faceted one. Rather tural competence training given the definition of than consider the construct as elusive or problem- cultural competence they espoused which was “a atic, we believe the work is still in progress. commitment and active engagement in a lifelong However, practitioners, educators, researchers, process that individuals enter into an ongoing administrators, and other stakeholders cannot basis with patients, communities, colleagues, and necessarily wait until a definition is perfectly 2 Cultural Competence 21 operationally defined and measurable. We rec- Bernhard, G., Knibbe, R. A., von Wolff, A., Dingoyan, D., Schulz, H., & Mösko, M. (2015). Development and ommend proceeding with caution, while actively psychometric evaluation of an instrument to assess pursuing self-awareness, knowledge of cultural cross-cultural competence of healthcare profession- others, and specific skills. We are particularly als (CCCHP). 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Roberto Rentería, Amber Schaefer, and Cristalís Capielo Rosario

Introduction O’Bryon, 2014). This problem is compounded by the frequent separation of ethical and multicul- Population projections estimate that by 2060, the tural concerns when working with clients. As USA will be a minority-majority country (Colby noted by Gallardo et al. (2009): & Ortman, 2015). As the population of the USA When the ethical lens supersedes the cultural lens becomes increasingly racially/ethnically diverse in a potentially “unclear” therapeutic encounter, (López, Bialik, & Radford, 2018; Vespa, thereby placing the clinician before the client, the Armstrong, & Medina, 2018) and more American clinician’s desire to “self-protect” may overshadow the clinical needs of the client. (p. 427). adults identify as LGBTQ+ (Newport, 2018), it is imperative for helping professionals to engage in This separation of multicultural and ethical con- therapeutic work that is both ethically and cultur- siderations may lead to practices that fail to con- ally informed. However, the provision of ethical sider the client’s presenting concerns within their and culturally informed practice continues to lag cultural contexts and instead impose Eurocentric, behind these changing demographics (Gallardo, heteronormative, and patriarchal values (Sue & Johnson, Parham, & Carter, 2009; Rogers & Sue, 2008; Wendt, Gone, & Nagata, 2015). O’Bryon, 2014). To illustrate, studies persistently Accordingly, it is critical to consider and rethink report how mental health professionals continue professional ethical codes and standards within a to work with Spanish-speaking clients (Castaño, culturally informed framework (Fisher, 2014). Biever, González, & Anderson, 2007; Delgado- This chapter provides a brief overview of pro- Romero et al., 2018; Delgado-Romero, Unkefer, fessional ethical codes in relation to multicultural Capielo, & Crowell, 2017; Verdinelli & Biever, ethics, ethical guidelines, and their juncture with 2009), LGBTQ+ individuals (Murphy, Rawlings, multicultural competencies. This is followed by a & Howe, 2002; Xavier et al., 2012), and people discussion of criticisms of ethical codes in rela- with disabilities (Man, Kangas, Trollor, & tion to multicultural counseling, an introduction Sweller, 2017; Rivas & Hill, 2018) without into the concept of multicultural ethical compe- receiving appropriate training (Rogers & tence, examples of culturally informed ethical decision-making frameworks, and examples of intersections between multicultural ethics and R. Rentería (*) · A. Schaefer · C. Capielo Rosario legal issues in working with diverse clients. Two Counseling and Counseling Psychology, Arizona ethical dilemma cases are presented along with State University, Tempe, AZ, USA e-mail: [email protected]; various recommendations and considerations. It [email protected]; [email protected] is important to clarify that the ethical decision-

Table 3.1 Resources for helping professionals and trainees Ethics guidelines and Ethics codes commentaries Practice guidelines American Association for National Latinx Psychological Competencies for counseling with transgender Marriage and Family Association (NLPA) Ethical clients (Burnes et al., 2010) Therapy (AAMFT) Code of Guidelines (2018) Ethics (2015) American Counseling Society of Indian Psychologists: APA guidelines for assessment of and Association (ACA) Code of Commentary on the APA’s intervention with persons with disabilities Ethics (2014) Ethical Principles of Psychologists and Code of Conduct (García & Tehee, 2014) Association of Black APA guidelines for psychological practice with Psychologists: Ethical girls and women Standards of Black Psychologists American Psychological APA guidelines for psychological practice with Association (APA) Ethical lesbian, gay, and bisexual clients Principles of Psychologists and Code of Conduct (2017) The National Association of APA guidelines for psychological practice with Social Workers (NASW) transgender and gender nonconforming people Code of Ethics (2017) Association for lesbian, gay, bisexual, and transgender issues in counseling (ALGBTIC) competencies for Counseling with lesbian, gay, bisexual, queer, questioning, intersex and ally individuals Association for Spiritual, ethical, and religious values in Counseling (ASERVIC) competencies for addressing spiritual and religious issues in Counseling Practical guidelines for counseling students with disabilities (Beecher, Rabe, & Wilder, 2004) making approaches provided here are not incorporate ethical principles and standards that exhaustive, but instead a guide of considerations provide recommendations to ensure the quality of as proposed by current multicultural competency professional practice and to protect the public guidelines. Also in this chapter a table (Table 3.1) (Francis & Dugger, 2014; Herlihy & Corey, of published ethical codes, practice guidelines, 2015). To distinguish these, principles tend to and commentaries from various organizations is refer to general aspirations or moral values, that provided as a resource for clinicians and clinical is, the moral values a profession aspires to achieve trainees. However, practitioners must be aware and embody (Kitchener, 1984; Pettifor, 2010). that this is not an exhaustive list and it is also For example, the American Psychological their responsibility to search for updates in ethi- Association (APA, 2017) code of ethics states that cal codes and standards of care. the principles it outlines should not necessarily be used to guide prescriptive behaviors, but instead provide an abstract goal of morality. APA’s code Professional Codes of Ethics prioritizes the principles of beneficence and nonmaleficence, fidelity and responsibility, integrity, Professional organizations within various helping justice, and respect for people’s rights and dignity professions have published ethical codes that (APA, 2017). In another example, the American 3 Ethics Culturally Diverse Clients 27

Counseling Association (ACA) outlines their fun- imposed upon those from different social and damental principles of ethical behavior as auton- cultural backgrounds. To illustrate, according to omy, nonmaleficence, beneficence, justice, the principle of beneficence of the APA Code of fidelity, and veracity (ACA, 2014). Similarly, the Conduct (APA, 2017), psychologists are asked to National Association of Social Workers (NASW) safeguard the rights of the individual and their states the principles of service, social justice, dig- autonomy. However, this principle may not align nity and worth of the person, importance of with values of interdependence that may guide human relationships, integrity, and competence the relationships and behaviors of allocentric (NASW, 2017). The American Association of communities, and thus may be counterproductive Marriage and Family Therapists (AAMFT) out- when working with these communities (Comas- lines six aspirational core values that similarly Díaz, 2014). resemble ethical principles distinct from stan- The assumed cultural neutrality of ethics dards (AAMFT, 2015). While each of these help- codes is also reflected on who is identified as the ing professions has a distinguishable identity and cultural being when the codes speak of the need focus, their ethical codes seem to be generally for professional and multicultural competence. guided by principles of justice, integrity, and Just as the communities served by practitioners, beneficence. Ethical standards, on the other hand, all helping professionals are shaped by cultural tend to be prescriptive behavioral rules and norms and social norms that are often grounded on able- to guide clinical practice. Licensing boards ism, cisgenderism, classism, heterosexism, nativ- throughout the USA, in turn, may use these stan- ism, and racism. As noted in the Society of Indian dards to determine whether professional behav- Psychologists’ APA Ethics Code Commentary iors towards clients, colleagues, and organizations (García & Tehee, 2014), “Cultural competence are ethical (Pettifor, 2010). begins with understanding your own values and biases” (p. 33). In other words, cultural competence requires the professional to be aware of Code of Ethics Criticisms how their culture and society influence them personally and, consequently, professionally. Yet, The use of these ethical standards by licensing this step is not clearly identified within the ethical boards is predicated on the idea that ethical stan- standards that speak of multicultural and/or pro- dards of the helping professions are morally and fessional competences. Instead, the helping pro- politically neutral (Comas-Díaz, 2014; Sue & fessional may be assumed as an acultural agent Sue, 2008). This notion, however, fails to recog- that uses acultural interventions meant to help the nize that ethics are inherently informed by cultur- cultural other. For example, in the APA Code of ally defined moral values and norms, meaning Conduct, Standard 2.01(b) Boundaries of that professional ethical codes are conceived Competence indicates: within a specific cultural, social, and political Where scientific or professional knowledge in the context. The ethical codes discussed here were discipline of psychology establishes that an under- developed within an American context, with standing of factors associated with age, gender, Eurocentric, individualistic, and patriarchal gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, lan- underpinnings. That is, a significant portion of guage, or socioeconomic status is essential for the research and practice writings that inform effective implementation of their services or ethical codes were primarily guided by White, research, psychologists have or obtain the training, male, affluent practitioners and researchers. experience, consultation, or supervision necessary to ensure the competence of their services, or they Thus, while these ethical standards and principles make appropriate referrals (APA, 2017, p. 5). are believed to be acultural, ethical codes generally reflect the cultural values and behaviors of This is the only standard that specifically the US White, middle, and upper class (e.g., indi- addresses multicultural competence in the entire viduality and privacy). These values are then APA ethical code. In the professional ethical 28 R. Rentería et al. code for social workers (NASW, 2017), social beliefs, and behaviors” (p. 5). As stated in this justice is itself outlined as an ethical principle, standard, the counselor is required to have self- including a call for social workers to “challenge awareness and understand how their values, social injustice…seek to promote sensitivity to beliefs, and behaviors may influence their inter- and knowledge about oppression and cultural and ventions. Furthermore, the ACA Code of Ethics ethnic diversity” (p. 2). This ethical code also consistently describes a call to cultural compe- includes specific standards for cultural competence and cultural considerations within various tence separate from a general competence stan- standards throughout the entire, demonstrating dard. Standard 1.05 Cultural Competency and an intentional integration of cultural focus Social Diversity includes four points providing through each standard of practice. Overall, the guidance for cultural competence: ethical codes of the helping professions present Social workers should understand culture and its very open and ambiguous calls for multicultural function in human behavior and society...Social competence. While ambiguity in the ethical workers should have knowledge based of their cli- codes is meant to facilitate a decision-making ents’ cultures and...demonstrate competence in the process that is inclusive of different perspectives provision of services that are sensitive to clients’ cultures…Finally, the Social Worker ethical stan- (Strech & Schildmann, 2011), a clearer articula- dards underscores the importance of seeking fur- tion of the helping professional as a cultural ther cultural competence when needed...Social being is required for multiculturally competent workers should obtain education about and seek to ethical decision-making. understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, and mental or Multicultural Ethical Competence physical disability. Regulatory bodies that operate by imposing rules The NASW (2017) also includes Standard 6.04 of conduct and strict behavioral code as a form of Social and Political Action which further outlines ethical guidelines without a thoughtful consider- a professional orientation to “engage in social ation to a multicultural philosophical foundation and political action that seeks to ensure that all or multicultural moral framework may be failing people have equal access to the resources, to provide ethical guidelines that truly seek the employment, services, and opportunities they beneficence of clients (Pettifor, 2010). To clarify, require to meet their basic human needs and to Pettifor (2010) states that a prescriptive approach develop fully” (p. 8). The standard includes a call to ethics is one that defines a standard of behavior for social workers to act against the exploitation focused on avoiding harm. Ethical codes utilizing and discrimination against a group of individuals this approach prioritize professionals doing the based on membership to a specific group. The “minimum required” amount of work by the AAMFT (2015) Code of Ethics emphasizes practitioner that ensures the reduction of risk of within their aspirational core values the impor- harm and to ensure there are no potential legal tance of “Diversity, equity, and excellence in and ethical repercussions. This practice does not clinical practice, research, education, and admin- truly focus on the client’s well-being and suc- istration” (p. 2). This code of ethics does not cessful treatment, and while it can be detrimental make further mention of cultural competence or to any client, it can become severely more dan- guidance in working with culturally diverse gerous for marginalized and/or minority commu- populations. nities that present with particular and unique Perhaps a better example of recognizing the presenting concerns. In contrast, an aspirational helping professional as cultural being is given by focus seeks optimal levels of care by promoting the ACA Code of Ethics’ Standard A.4.b. (2014), the respect, integrity, and genuine interest of in which the counselor is asked to be “aware of— upholding ethical principles in order to obtain the and avoid imposing—their own values, attitudes, welfare of the client. Of course, a prescriptive 3 Ethics Culturally Diverse Clients 29 approach may be easier as it provides signifi- tudes that systematically endanger the well- cantly easier framework to determine unethical being of others. or ethical behavior: either you performed an Conversely, Fisher (2014) calls for the consid- action, or you did not. eration of ethical contextualism or universalist The danger of lacking a multicultural moral approach, a framework that blends the two previ- framework and the application of a prescriptive ously mentioned approaches. In this moral frame- ethics approach runs the risk of practicing unin- work there is a recognition for certain universal tentionally racist and culturally insensitive coun- moral values given a shared humanity, while also seling practices and ethical decision-making recognizing that individual cultural groups have (Gallardo et al., 2009; Pedersen, 1997). For unique values (Pedersen, 1997). Moral principles example, a moral framework that lacks engage- such as beneficence, integrity, respect for human ment in a critical examination of its own cultural dignity, and freedom may be considered univer- biases may result in an ethnocentric thinking, that sal and as guides in attempting to make an ethical is, judging others’ behaviors, emotions, and decision, while also considering the values of a thoughts based on one’s own ethnic/racial per- client’s cultural groups and identities to further spective. This may then lead to the pathologizing guide the decision-making process. This process of diverse cultural practices and ultimately fail to requires an active and intentional exploration of truly serve clients in need. the practitioner’s and the client’s sociocultural The lens utilized to understand ethical prin- context and moral values to negotiate a clinical ciples and standards also influences how practi- decision that aspires towards those universal tioners solve ethical dilemmas (Bernal & moral values and that also remains congruent Domenech Rodríguez, 2012). Fisher (2014) with the client’s own set of beliefs (Gallardo describes three ethical decision-making et al., 2009). approaches often utilized in the helping profes- Linked to the previous moral framework, the sions: ethical absolutism, ethical relativism, and concept of multicultural ethical competence is ethical contextualism. An absolutist approach or considered, which refers to a “process that draws ethical absolutism describes an approach where on psychologists’ human responsiveness to those ethical standards and codes of ethics trump con- with whom they work and awareness of their own textual factors and dynamics within the interper- boundaries, competencies, and obligations” sonal relationship. That is, in this approach the (Fisher, 2014, p. 36). Therefore, it is not suffi- practitioner would be indifferent towards con- cient to be solely aware of one’s own cultural val- textual factors, including people, situations, and ues and biases, but rather to also critically other social influences and instead attempt to consider the ways in which one’s values interplay apply a “one-size-fits-all” approach (Fisher, within the context of a counseling situation. 2013). This approach is typically associated with Specifically, practitioners carry the heavy burden the belief that psychological practice and ethical of being able to accurately gather information standards are “objective” and universal. On the from clients in a manner that can provide a diag- other hand, ethical relativism denies such exis- nosis which can influence. tence of universality and rejects the so-called A potential moral framework to consider common moral values among all members of the would be “virtue ethics,” a moral framework that human race. Instead, this approach accepts that considers cultural contexts and focuses on the cultural groups have their own set of cultural and importance of genuinely seeking the well-being moral frameworks. In this instance, ethical deci- of the individual (Fowers & Davidov, 2006; sion-making would occur within the confines of Meara, Schmidt, & Day, 1996). In contrast to the the moral framework of that cultural group. This prescriptive ethics approach discussed earlier in approach may also result in certain risky impli- this chapter, virtue ethics provides an approach of cations, specifically in cases where a cultural considering the unique needs of an individual and group may ascribe to behaviors, beliefs, and atti- making decisions towards the beneficence and 30 R. Rentería et al. service of the individual, as opposed to simply Researchers and practicing professionals have following the “correct” rules and “minimum begun pushing for guidelines that demonstrate required” responsibilities. Instead, virtue ethics cultural awareness and service guidelines. To sees the helping professional as a virtuous agent begin, a critical piece authored by Sue, Arredondo, motivated to do good. The virtuous helping pro- and McDavis (1992) sought to initiate the con- fessional is one who also considers the role of versation surrounding multicultural guidelines emotions in multicultural ethical decision- that aimed to redirect the previously misguided making and understands the role the community ethical standards that demonstrated ethnocen- they serve in the decision-making process (Meara trism, a preference towards individualistic cul- et al., 1996; Trimble & Fisher, 2006). tures, valued Western practices and beliefs over Eastern approaches, and the role of mental health service providers play in the realm of advocacy Multicultural Ethical Decision-Making for their clients. This article also called for Models changes in the counseling program accreditation process (e.g., incorporation of multicultural Ethical violations transpire when agreed-upon courses and competencies as a core component moral imperatives are violated (e.g., engaging on of their training models). Specifically, the authors a sexual relationship with a client) (National of this article served as pioneers in the field of the Latinx Psychological Association, [NLPA] development of several counseling competencies 2018). While ethical violations are often clear to and areas of research, including, but not limited identify, ethical dilemmas are more difficult to to, guidance on the development of school and identify and solve because they often occur guidance counseling programs (Gysbers & within a context of competing demands for Henderson, 2012), basis for research on microag- action that could be similarly valid depending on gressions in counseling (Shelton & Delgado- the values, beliefs, and traditions of the profes- Romero, 2013; Sue et al., 2007), and other critical sional and the community they serve (NLPA, expansions to multicultural competence and clin- 2018). The vague language used by the ethical ical practice (Arredondo et al., 1996; Constantine, codes aforementioned (e.g., referring their Hage, Kindaichi, & Bryant, 2007; Goodman respective professionals to simply consider mul- et al., 2004; Vera & Speight, 2003). ticultural factors in the ethical decision-making Another pivotal article that sought to directly process) makes the process of multicultural ethi- challenge the ethnocentric approaches of the cal decision-making increasingly difficult. mental health professions, particularly those of Therefore, even clinicians who strive to provide mental health counseling and counseling psy- multiculturally competent services could find chology, was written later by Arredondo and this process to be daunting simply due to lack of Toporek (2004), wherein the authors highlighted specificity as it relates to multicultural and/or the ways in which the mental health profession professional competence and minimal training was neglecting the needs of entire populations. focus on multicultural ethics decision-making As a result, they reported the alarming concern of (NLPA, 2018). To address this, various ethical higher attrition rates in counseling among ethni- decision-making models have been proposed to cally diverse groups of clients. Within the context guide practitioners, more than could be fully of highlighting the deficits of the field, this article covered in this chapter. The following sections also provided suggestions and resources to the discuss historical and contemporary models of readers. Specific case examples also provided multicultural ethical competence, multicultural readers with the knowledge base of case studies decision-making, and provide resources practi- that outline the complexity of the nature of the tioners can use in their work with clients of counseling relationship with special regard and diverse cultural, ethnic, and socioeconomic attention given to context, multicultural aware- backgrounds. ness, and the history of marginalization being 3 Ethics Culturally Diverse Clients 31 perpetuated within the field of the “helping” pro- political factors are continuously changing and fessions. Perhaps most fundamental about this influencing both the professional and the client, seminal article is its direct attempt to outline mul- the professional and regulatory bodies who inter- ticultural competencies as alive and malleable, pret ethical guidelines and standards must also be designed to be ever-changing as to best meet the willing to adapt, learn, and grow. As will be needs of clients. In addition to providing specific explored later in this chapter, taking a client out guidelines of how to begin working in a cultur- of the context of their situation is not only insuf- ally sensitive manner with culturally diverse cli- ficient in meeting the counseling goals for a clients, the authors also remind practitioners to ent, but also can result in harm to the client and continually be aware and to evaluate their own their community. multicultural values and biases. Multicultural ethical competence and ethical Even prior to some of the previously men- decision-making must begin with the helping tioned seminal articles that aimed at creating professional taking inventory of their values and ethical guidelines for practice with culturally beliefs and understand how these values and diverse populations was consequential article beliefs influence their interpretation of ethical authored by Casas, Ponterotto, and Gutierrez principles and standards as well as how they (1986). This article emphasized how mental solve ethical dilemmas. It is also necessary to health professionals who are not multiculturally understand that ethics exist within a cultural, competent should be considered unethical. It social, political, and historical context. To facili- could even be argued that this bold statement was tate this process, Toporek and Reza (2001) pro- one of the pivotal moments in multicultural psy- pose in their article the Multicultural Counseling chology, as it served as one of the catalysts Competency and Planning Model (MCCAP) as a towards calling out counselors who did not har- model to assisting professionals in growing in bor the ability to work both effectively and ethi- their cultural competence. The authors present cally with clients of diverse backgrounds. After this model as a “cube” where the standards and this article, the articles previously cited in the competencies of Sue et al. (1992) are considered preceding paragraphs continued the momentum on the intersection of context and assessment and of several years of conversations on the topic of plan components. The context refers to the coun- working with clients not of the Anglo-European selor, whether they are functioning within per- heritage. These conversations continue today, sonal (e.g., identity, beliefs, attitudes), resulting in continued efforts from concerned professional (professional identity), and institu- experts in the field to strive to develop new ethi- tional (e.g., agency, institution of employment, cal guidelines specific to diverse clients. local, state) environments. The assessment and Being multiculturally competent is an ever- plan components refer to the specific actions and changing process that does not end at a specific plans that practitioner sets out to develop in their point in time (Arredondo & Toporek, 2004). As competences, beginning with the assessment of such, a practicing mental health professional what one already knows, what is information is does not arrive at a point of multicultural compe- needed, and how that awareness and knowledge tence, but instead is continually striving to remain will be raised. Finally, the authors posit that these an active learner of issues in counseling. Per changes towards cultural competence need to Casas et al. (1986) and Toporek and Reza (2001), occur within three domains: emotional, cogni- a competent clinician must consider context, tive, and behavioral. sociopolitical factors, language, religious, and The National Latinx Psychological the socioeconomic status of a client, couple, or Association also provides an ethical decision- family when considering assessment, diagnosis, making model within their ethical guidelines that and treatment. The same care should be taken calls for flexibility and contextualization (NLPA, when solving ethical dilemmas. Because socio- 2018). Generally, they propose common steps: 32 R. Rentería et al.

(a) clarifying the nature of the dilemma, (b) ana- ginalized communities also exist within legal lyzing legal and ethical responsibilities, (c) oppressive systems. Such systems may be past or consulting with other professionals, sources, and current, and in either case, they may have active community members that could be potentially and current impacts on the lives of clients. Thus, affected by the decision, and (d) brainstorming it is an ethical duty to be aware and proactive in for many possible actions and myriad conse- preparing for the challenges faced when multi- quences. Authors of the NLPA ethical guidelines cultural ethics and the law may be at odds. In the emphasize that the ethical decision-making pro- following, a few examples of current important cess is a life-long process of growth and learning. legal issues are discussed. Again, this list is not They also strongly recommend approaching ethi- exhaustive and may also be continuously chang- cal decisions and conclusions to be “held with an ing as awareness and knowledge increase. Some open hand” (p. 25) that is, recognizing that deci- of the legal issues discussed in the following may sions can be valid and useful while also under- include laws that directly impact the training and/ standing that they may be fallible. or practice of helping professions while other Another potential resource for helping profes- examples refer to general implications of how sionals is the “Ethics and decision making in legal systems impact and potentially oppress counseling and psychotherapy” chapter by entire communities. Cottone and Tarvydas (2016). In this chapter, the authors present a review table of various commonly used models of ethical decision-making, Conscience Clause providing a description on the various steps and considerations within each model. Furthermore, A current conflict within culturally informed the authors provide an in-depth description on the ethics and law focuses on the conscience clause. Tarvydas Integrative Model, composed of 4 Based on the legislation passed in Arizona stages: (1) interpreting the situation through Statute, this clause reads that “a university or awareness and fact finding, (2) formulating an community college shall not discipline or dis- ethical decision, (3) selecting an action by weigh- criminate against a student in counseling, social ing competing, nonmoral values, personal blind work, or psychology program because the stu- spots, or prejudices, and (4) planning and execut- dent refuses to counsel a client about goals that ing the selected course of action. These resources conflict with the student’s sincerely held reli- are considered to be useful for clinicians to gious belief…” (H.B. 2565, 2017). In effect, engage with current ethical decision-making this law allowed practicum students to refuse models. Nonetheless, it is strongly emphasized clients with presenting concerns that contradict that helping professionals actively seek up-to- sincerely held religious beliefs, including a date models and ethical concepts as these con- sexual minority orientation, gender minority tinue to develop as practitioners gain a better orientation, and even clients that may be understanding of human diversity and ethical ascribed to a different set of religious beliefs. issues. Ethical codes within helping professions are quite clear of the importance of competence in working with diverse clients, specifically in the Ethical and Legal Issues ethical requirement of practitioners seeking competency through training, supervision, and Beyond the implications of ethical decision- consultation when working with culturally making within clinical decisions, ethics also diverse clients they may have little experience largely intersect with important legal implica- with. Conscience clauses then directly contra- tions. This is of particular importance in the work dict ethical guidelines as set by professional with marginalized communities, as many mar- organizations. 3 Ethics Culturally Diverse Clients 33

Immigration and DACA Case Examples and Ethical Decision-Making Approximately 10.7 million (Krogstad, Passel, & Cohn, 2017) immigrants are currently living In the following, two cases of ethical dilemmas in the USA without documentation and approx- are presented that include multicultural issues. imately 700,000 individuals are currently Recommendations are provided after each case. enrolled in the Deferred Action for Childhood It is important to emphasize that this chapter is Arrivals (DACA) program (U.S. Citizenship only providing a few examples of how a practi- and Immigration Services, 2019). For these tioner may consider ethical dilemmas and that communities, the lack of a recognized “legal these approaches are not being presented as the status” by the US federal government has sig- only possible manner to making multiculturally nificant psychological and social implications. competent ethical decisions. Ethical dilemmas Significant empirical research supports how are immensely complex and so it would be documentation stress/marginalization is asso- impossible to provide a comprehensive and abso- ciated with higher risk of physical, emotional, lute “solution.” The following are provided as and academic disparities (Gonzales, Suárez- examples of how a clinician may go about con- Orozco, & Dedios-Sanguineti, 2013; Roth, sidering the issues and factors that interplay in an 2017). Within the context of ethical multicul- ethical dilemma. tural practice, practitioners serving members of this community and/or clients who may be closely associated with this community should Case #1 be informed about the legal issues that impact this community, as well as the social, cultural, Ceci is a 20-year-old, heterosexual, Latina and health implications that this may have. women, currently unmarried and living with Furthermore, sensitivity regarding this identity her parents. Ceci came to the USA with her must be practiced (e.g., setting additional safe- family from El Salvador when she was 12 years guards for confidentiality and note taking; old. She has attended two counseling sessions, Delgado-Romero, Nevels, Capielo, Galván, & reporting various anxiety symptoms. When Torres, 2013). Confidentiality is more criti- Ceci arrives to her third session, she reports that cally emphasized given the huge risks of during the past week she has been seeing large deportation that could occur if a client’s legal floating devices that have been following her status was discovered. Within the context of around. Ceci stated she believes these devices virtue ethics and multicultural ethical practice, are sending information about her to a secret a practitioner needs to be prepared in advance government agency documenting her every to advocate on behalf of and protect their cli- behavior. Ceci also said that she has been hear- ent’s documentation status in the case of a ing voices that have been helping her plan how medical emergency, legal situation, or in a situ- to attack and destroy the devices. The clinician ation where a client may need to contact the is strongly considering hospitalization, suspect- authorities. Participating in Know your Rights ing that Ceci is having a psychotic episode. workshops and educating their clients about However, the clinician remembered Ceci the client’s rights is a necessity when working reported in an earlier session that she and her with this community (Chavez-Dueñas & parents are undocumented and is concerned Adames, 2017, 2018). that hospitalization may put Ceci and/or her 34 R. Rentería et al. family at risk for deportation. The clinician is It is imperative at this point for the clinician to uncertain if Ceci will pose a risk to herself and contact and inform Ceci’s parents and obtain others but is concerned her symptoms may consultation from other colleagues. The clinician worsen if she is not placed in psychiatric care. should consider the potential actions that could The clinician is also aware the latter option may be taken to ensure that Ceci is not a danger to have worse implications for Ceci and her fam- herself and towards others. This may include ily if legal authorities became involved with the physically accompanying Ceci and her family to case. The clinician needs to decide soon as Ceci a hospital or psychiatric center. This may be ben- is getting ready to return home at the end of the eficial in that it would allow the clinician to advo- session. cate in the hospital for their client. If the clinician is unable to accompany, they may consider asking for permission to contact a trusted family Considerations member, neighbor, religious leaders, immigration rights advocate that may be able to accom- In the previous example, there are multiple ethi- pany. As mentioned previously, many of these cal code standards that may influence the deci- possible actions require the clinician to be pre- sion that a clinician could take regarding Ceci’s emptively prepared for these sorts of emergen- situation. This case makes it imperative for the cies and also necessitate an understanding of the clinician to be familiar with undocumented client’s social network to provide culturally migrant rights prior to this sort of circumstance to informed recommendations. occur. This calls for clinicians to be preemptively prepared and aware of potential ethical and legal issues that may arise when working with popula- Case #2 tions who may be particularly vulnerable to legal action. Chaske is a 9-year-old Sioux boy who was being In the decision-making process given this seen on a bimonthly basis by an outpatient multi- case, a clinician would strive to “avoid harm,” disciplinary nephrology transplant team. During that is, an attempt to minimize or to remedy a routine visit, a social work practicum student unavoidable or anticipated harm. The clinician was staffed to the case when a nurse practitioner has assessed that Ceci may not be in a mental noticed some unexplained bruises on the patient’s state to be left without clinical oversight and arms. When the practicum student’s clinical may be a danger to herself. While Ceci did not supervisor asked the patient about the origin of make statements of harming others, due to her the bruises, the father was the first to reply and psychotic symptoms, she may put others at risk began telling a long recount of different commu- if her symptoms worsen. The clinician must nity events and celebrations that led up to the then consider the risk. Now, the next steps that incident involving the bruises, as well as incorpo- the clinician takes to ensure that Ceci is safe are rating some humor into the situation. Given the of critical importance. Ceci’s legal status may nature of the father’s testimony and how it be another level of potential risk and harm for included seemingly unrelated details and light- the client: if hospitalizing leads to Ceci’s immi- heartedness, the supervisor decided to meet indi- gration status being questioned by authorities, vidually with the patient to ask more questions. she may be at risk for deportation. In this case, The patient responded to the supervisor’s direct the clinician must consider Ceci’s sociopolitical and aggressive questioning style in a similar pat- reality and consider that the risk of deportation tern, including various details of other seemingly may be a higher risk of harm for her client. unrelated events before denying that the bruises However, due to Ceci’s symptoms, to not place were a result of any abuse or neglect. her under professional clinical care would also Based on the style of communication from be harming. the patient and family, the supervisor determined 3 Ethics Culturally Diverse Clients 35 that there was likely manipulation and lying to Conclusion hide the true reason behind the bruises, ultimately asking the student to make a report to the The field of multicultural competence is fast- Department of Children and Families (DCF). growing and dynamic. Consequently, the moral When the practicum student raised concern that frameworks and approaches that guide multicul- this report was being made prematurely, citing tural ethics must be also continuously challenged literature on narrative communication patterns and changed to truly serve and help communities. and humor being more common among some This increases the challenge of maintaining mul- Native American communities (Garrett et al., ticultural ethical decision-making within clinical 2017; Thomason, 1991), the supervisor quickly practice. Human diversity is infinitesimally com- dismissed the suggestion and herself cited the plex, precluding the development of a standard Social Work Ethical Guidelines (NASW, 2017). ethical decision-making process that can be truly Ultimately, the DCF case was closed due to culturally competent. Instead, practitioners need unfounded evidence of abuse or neglect. to develop a critical consciousness regarding However, the family suffered severe conse- moral frameworks and ethical guidelines and quences of having their community disrupted continue engaging in self-reflection to further and questioned when case workers came out to develop a multicultural ethical competence. interview the family on their reservation. After By engaging in a process of continuous self- the event, the family transferred their care to a reflection, addressing one’s own privileges, different hospital for fear of being judged or mis- power dynamics, and cultural biases in relation to understood again in the future. “morality,” practitioners can better practice remaining open to new cultural frameworks of morality. The conversation of ethics remains Considerations opened and many ethical dilemmas remained unanswered, but the importance is to remember There are several ethical guidelines upon with that the critical and important role of the practi- to reflect when considering this case. To begin, tioner is to prioritize the welfare and well-being the clinical supervisor, while considering the of the client and to utilize training, supervision, ethical guidelines of social workers having a consultation, and empirical research to continue duty to report suspected abuse or neglect of a ethical practice with diverse clients. child, neglected to consider the cultural components that may have led to the interpreted “deceitful” pattern of communication from the References family. The code of ethics for social work clearly outlines the ethical necessity of having a American Association for Marriage and Family Therapy. multicultural knowledge prior to walking into a (2015). AAMFT code of ethics. Retrieved from https:// www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx therapeutic relationship with a client of Native American Counseling Association. (2014). ACA code of American heritage was key in this case. The ethics. Alexandria, VA: Author. supervisor in this example did not demonstrate American Psychological Association. (2017). Ethical cultural knowledge, ultimately resulting in the principles of psychologists and code of conduct. Washington, DC: Author. suggestion to file an unjustified case of neglect. Arredondo, P., & Toporek, R. (2004). Multicultural coun- Had the supervisor considered the suggestion seling competencies = ethical practice. Journal of of the supervisee, there could have been a Mental Health Counseling, 26(1), 44–55. chance that the supervisor would not have inter- Arredondo, P., Toporek, R., Brown, S. P., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996). preted the communication style of the patient Operationalization of the multicultural counseling and his family as manipulative or as avoiding competencies. Journal of Multicultural Counseling & the question. Development, 24, 42–78. 36 R. Rentería et al.

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Deidre M. Anglin, Rachel Tayler, and Rona Tarazi

James1 is a 29-year-old Afro-Latino, Christian that often shape the day-to-day experiences of male who identifies as cis-gendered and bisexual. individuals (e.g., probability of experiencing His parents are monolingual Spanish speaking and racial microaggressions; exposure to adversity). are members of the working poor class. He is a second-generation immigrant who grew up speak- This chapter describes some of these epidemio- ing English and Spanish in his home. James is a logical factors to consider when working with member of the upper middle class and works in the diverse groups of clients like James. financial services industry as an analyst. He reports feeling depressed (low mood, anhedonia, and irritability) as well as having some unusual perceptual experiences. Theoretical Models of Risk: Socioeconomic Status and Race Clinicians are used to treating individuals like James who present with rich backgrounds, a mix- Social causation and social selection are two ture of group identities, and psychological dis- theoretical mechanisms proposed in epidemio- tress and symptoms. While clinical training often logical literature to explain why membership to emphasizes the individual-level analysis of group identities that experience adversity is symptomatology, individuals also hold group associated with mental health clinical outcomes identities situated in communities that corre- (Dohrenwend et al., 1992). The theory of social spond to varying structures within the greater causation predicts that the adversity and life society. Accordingly, population-level risk fac- stress experienced by disadvantaged ethnic tors are associated with these group identities groups of low SES leads to higher rates of psychopathology compared to higher SES groups. 1 James is a completely fictitious person created for illus- Consequently, groups with lower socioeco- trative purposes. nomic status (SES) are more vulnerable to mental illness illustrating the inverse relationship D. M. Anglin (*) that exists between psychiatric disorders and The City College, City University of New York, SES (Dohrenwend et al., 1992). In contrast, New York, NY, USA social selection predicts that having mental ill- The Graduate Center, City University of New York, ness limits social mobility, access to resources, New York, NY, USA e-mail: [email protected] and occupational attainment. As a result, off- spring of affected individuals, who are geneti- R. Tayler · R. Tarazi The City College, City University of New York, cally more at risk for their parental disorders, New York, NY, USA are born into a lower status thereby limiting

© Springer Nature Switzerland AG 2020 39 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_4 40 D. M. Anglin et al. income and continuing their downward drift. In plays in these relationships. Colen, Ramey, this situation, the social adversity does not cause Cooksey, and Williams (2017) analyzed a nation- stress and subsequent mental disorder, rather, ally representative sample of longitudinal data genetic vulnerability creates the association collected over a 33-year time span to assess the between mental illness and low SES. relationship between socioeconomic mobility, Bruce Dohrenwend and colleagues’ ground- exposure to discrimination, and self-rated health breaking Science article in 1992 put these in African Americans, Latinos, and Whites. mechanisms to the test using an Israeli birth Despite all three groups having access to above cohort study of 4914 respondents, in which the average social and economic resources, nonpoor prevalence of psychiatric disorders was com- African Americans and Latinos reported signifi- pared across four groups: high SES racial cantly worse health compared to nonpoor Whites. minority, high SES racial majority, low SES The results also showed a key difference in the racial minority, and low SES racial majority. association between SES and unfair treatment Dohrenwend et al. (1992) tested this classical across race. Moderate income gains for Whites epidemiological issue by focusing on ethnic sta- over time resulted in significantly less exposure tus in relation to SES. Because of ethnic preju- to both acute and chronic discrimination. African dice and discrimination, members of Americans, on the other hand, did not reap the disadvantaged ethnic groups are more likely to same benefit from upward mobility. African experience barriers against achieving highly Americans whose incomes moderately increased valued goals (Dohrenwend et al., 1992). These over time were significantly more likely to expe- barriers, which restrict mobility opportunities, rience acute discrimination and just as likely to affect disadvantaged ethnic groups at every experience chronic discrimination compared to level of SES. Dohrenwend et al. (1992) found their socioeconomically stable counterparts. For that for most mental health disorders studied, African Americans, acute experiences of racial specifically depression, substance use, and anti- discrimination may attenuate the health benefits social personality disorder, social causation fac- of having more socioeconomic resources. These tors were dominant. These disorders were findings support an increasing body of research significantly higher among the racially disad- that argues that the meaning of SES, and the rela- vantaged low SES groups. tionship between SES and health differs based on In contrast, they found that social selection racial status in part due to racial discrimination mechanisms may explain the relation between (Colen et al., 2017). low SES and mental disorders, specifically for When unfair treatment is experienced as a schizophrenia (Dohrenwend et al., 1992). When psychosocial threat, a stress response is acti- social selection causal mechanisms are operat- vated via the hypothalamic-pituitary-adrenal ing, the rates of disorder among the high SES axis (HPA axis). When the HPA axis is acti- group should be lower for racially disadvantaged vated, a mixture of hormones that include corti- groups compared to racially advantaged groups sol and epinephrine are released that trigger a because the more advantaged ethnic group will cascade of physiological stress responses in the be more likely to be able to support unhealthy body (Cohen et al., 2006; Cunningham et al., individuals at higher SES levels and only the 2012). These responses include increased heart healthy racially disadvantaged individuals would rate, elevated blood pressure, and respiration. be able to endure discrimination and rise to and/ Health outcomes are worse for those who or maintain their high SES. repeatedly experience this stress response and Recent epidemiological studies provide evi- those who cannot turn off this physiological dence that supports social causation (van Os & cascade once it is activated (Schneiderman, McGuffin, 2003). The theory not only explains Ironson, & Siegel, 2005). the relationships between SES, race, and health, Racial discrimination can be chronic, where but it also identifies the role racial discrimination there are enduring and recurrent exposures that 4 Epidemiological Considerations Working with Culturally Diverse Populations 41 persist over long spans of time (Ong, Fuller- worldwide (Murray & Lopez, 1996a), and is pro- Rowell, & Burrow, 2009). An example of chronic jected to be the second leading cause of disability racial discrimination is being talked down to by worldwide by 2020 (Murray & Lopez, 1996b). teachers and later colleagues or being ignored or As of 2016, the prevalence of MDD in US adults not trusted to have knowledge. Racial discrimina- was 6.7%, or 16.2 million adults (National tion can also be daily, where the experience has a Institute of Mental Health, 2017). In the U.S., its discrete onset and end. An example of daily racial economic burden was estimated to be $83 billion discrimination is getting stared at suspiciously in the year 2000 (Williams et al., 2007). Research while shopping in a store or being harassed by the has indicated that the relationship between MDD police. Regardless of the frequency, racial discrim- and race or ethnicity is complex. ination acts as a stressor in the marginalized indi- Williams et al. (2007) investigated the preva- vidual’s life. Racial discrimination has primary lence and course of MDD in Blacks and Whites effects, where strains and hardship occur over time living in the U.S. The study employed a national and day to day, or secondary effects, where nega- household probability sample (N = 6082) of tive life events happen as a result of chronic and African Americans, Caribbean blacks, and non- daily exposure to racial discrimination (Ong et al., Hispanic whites between February of 2001 and 2009). Both stressors can operate in an additive June of 2003. While they found 12-month esti- fashion and increase psychological distress. mate of MDD was similar across groups, the life- A study assessed how racial discrimination time prevalence was highest for non-Hispanic was related to mental health outcomes using a Whites. But for the course of MDD, Williams sample consisting of 174 African American et al. (2007) found the chronicity of MDD was graduate students who were asked to complete worse for both African Americans and Caribbean daily, online diaries over a two-week span (Ong blacks compared to Whites, and that both Black et al., 2009). The diaries were completed during groups were more likely than Whites to rate their the same time period, and self-report question- depression as disabling, severe, or very severe. naires were used to obtain additional informa- Furthermore, less than half of African Americans, tion. The authors found that racial discrimination and less than a quarter of Caribbean blacks among African Americans has a detrimental received any form of therapy for MDD (Williams effect on well-being and this is demonstrated et al., 2007). These findings suggest that while across several psychological outcomes. The Blacks may be less likely than Whites to have a stress and consequences associated with racial depressive episode in their lifetime, any given discrimination multiply to create other stresses episode will be more likely to be disabling and go across a variety of domains such as family, untreated. health, and finances. Therefore, the variability in The relationship between race and psychosis how individuals are impacted by racial discrimi- is also complex. There is a long-standing suppo- nation may lie in the different configurations of sition that individuals of African descent, or primary and secondary stressors the person is Blacks, are at an increased risk for developing exposed to (Ong et al., 2009). psychotic spectrum disorders, and in particular schizophrenia (Barnes, 2004; Schwartz & Blankenship, 2014). Much of the research Disparities in the Prevalence supporting this supposition has emanated from and Course of Psychiatric Disorders Europe. For example, studies conducted in the United Kingdom have consistently found higher Groups of African Descent risk for schizophrenia, as high as an 18-fold increase, among Black immigrants compare to Major depressive disorder (MDD) is a common ethnically white Brits (Anglin, Lee, Yang, Lo, & psychiatric disorder in the United States (U.S.), Opler, 2010). But studies conducted on Blacks that is the fourth leading cause of disability who reside in their countries of origin, such as 42 D. M. Anglin et al.

Jamaica and Trinidad and Tobago, and various clinical diagnosis other than bipolar or schizoaf- countries in Africa, provide weak to no evidence fective disorder. The authors concluded that clini- that schizophrenia and psychosis are elevated in cians may have more difficulty identifying mania these populations. As a result, the process of in any patient with psychosis, and that this diffi- migration and the social environment have been culty was more apparent among African American implicated as risk factors for psychosis (Anglin patients (Strakowski, Mcelroy, et al., 1996). et al., 2010). Other US-based studies found a disparity In the US., results from nationally representa- between African Americans and Whites in the tive epidemiologic studies suggest elevation in prevalence of symptoms and disorders across the the incidence and prevalence of psychosis among psychotic spectrum. A birth cohort study of an groups of African ancestry is in large part urban, insured US population found a twofold to explained by the confounding of SES with race threefold increase in schizophrenia for African (Robins & Reiger, 1991), or by racial biases in Americans compared to non-Latino Whites the diagnostic process (Anglin & Malaspina, (Bresnahan et al., 2007) and studies of subthresh- 2008). Misdiagnosis and diagnostic instability old psychosis find racial disparities, with Blacks have been shown to be greater among African and Latinos exhibiting higher symptom probabil- American patients compared to other racial ity and frequency than Whites (Schwartz & groups (Anglin & Malaspina, 2008). This rate of Blankenship, 2014). misdiagnosis has been attributed to factors such as social distance, clinician bias, differential adherence to diagnostic criteria, and differential Immigrants of Color: The Immigrant symptoms endorsement among Black patients Paradox (Whaley, 2001). A study by Strakowski and colleagues at the University of Cincinnati Epidemiological studies find differences in the (Strakowski et al., 1996) found that African prevalence of psychological disorders across Americans were more likely than Caucasians to immigrant status (Teruya & Bazargan-Hejazi, receive a diagnosis of schizophrenia and less 2013). Often termed the “immigrant paradox,” likely to receive a diagnosis of psychotic depres- first generation immigrants tend to exhibit better sion. This difference held even though the rate of health outcomes than US born second-genera- current depressive episodes reported by the tion immigrants and Whites despite generally Caucasian and African American samples was having less access to socioeconomic resources very similar (Strakowski, Flaum, et al., 1996). (Alcántara, Estevez, & Alegría, 2017). In a different sample of 100 patients who met Acculturation which is defined as “the changes DSM-III-R criteria for bipolar disorder or that take place as a result of contact with cultur- schizoaffective disorder, bipolar type, with cur- ally dissimilar people, groups, and social influ- rent psychotic mania, Strakowski, Mcelroy, ences” (Gibson, 2001, p. 19) may have an impact Keck, and West (1996) compared clinical diagno- on health outcomes and offer protective factors. ses with research diagnoses on the same patients. Research studies have shown that greater degrees Participants were given research diagnoses using of acculturation are associated with poorer the Structured Clinical Interview for DSM-III-R health outcomes (Alegria et al., 2004; Alegría (SCID-P), and clinical diagnoses from the et al., 2008). As an immigrant’s exposure to Psychiatric Emergency Service at the time of mainstream US culture increases, more psycho- admission. They found that there was no differ- logical difficulties are experienced. It has been ence in research SCID diagnoses between the argued in the literature that a lesser degree of African American and Caucasian patients with acculturation may be a protective factor. For psychotic mania. However, there was a difference example, one study found that Hispanic adoles- in the clinical diagnoses, where African cents who spoke mostly Spanish and engaged in Americans were more likely to have received a Hispanic cultural practices (as a measurement of 4 Epidemiological Considerations Working with Culturally Diverse Populations 43 acculturation) were less likely to use drugs and A study of the prevalence of mental health dis- alcohol, and more likely to be physically active orders among a nationally representative sample (an indicator of healthy behaviors) (Alegría of Asians found that US born Asians had the et al., 2008). highest rates of any disorder (i.e., depression, Latino immigrants reported decreased rates of anxiety, substance use) compared to non-US born substance use and anxiety disorder when com- Asians (Takeuchi, Alegría, Jackson, & Williams, pared to US born Latinos, and non-Latino white 2007). However, indicators of acculturation such individuals (Alegría et al., 2008). In order to as English proficiency, and age at migration and study this discrepancy, Alegría and colleagues gender impacted the results. Proficiency in combined and examined data from the National English was protective for Asian men, particu- Latino and Asian American Study (NLAAS) and larly with regards to depression and anxiety. the National Comorbidity Survey Replication Immigration as an adult was also a protective fac- (NCS-R), two of the largest nationally represen- tor, particularly for women. Overall, the immi- tative samples of psychiatric information. Data grant paradox was most consistent for substance was collected through interviews conducted use, especially in men (Alegria et al., 2004; either in Spanish or in English and analyzed to Takeuchi et al., 2007). generate a lifetime and 12-month diagnosis using The long-term psychological consequences of DSM-IV and ICD-10 diagnostic systems. Even the process of acculturation are variable, depend- when controlling for age and gender, the authors ing on social and personal factors that exist in the still found differences between Latino and non- society of origin, the society of settlement, and Latino White subjects, where US-born non- variables that exist both prior to, and arise during, Latino white subjects reported higher rates of the course of acculturation (Berry, 1997). disorders compared with US-born Latino sub- Individuals begin the acculturation process with jects (Alegría et al., 2008). several personal factors of both demographic and When disaggregated into ethnic groups, the social nature that influence their acculturation authors found significant differences in rates of process (Berry, 1997). Age, for example, is psychiatric disorders. The rate for lifetime disor- known to have a direct relationship to accultura- der was highest among Puerto Ricans (37.4%), tion, where individuals who immigrate at a young followed by Mexican subjects (29.5%), Cuban age are more likely to absorb the receiving coun- subjects (28.2%), and other Latino subjects try’s cultures, customs, and values as compared (27%). While rates of depressive disorders were to an individual who immigrates as an adult not found to be significantly different between (Berry, 1980). Acculturation also depends on Latino groups, the rate of substance use among both the societies of origin and of settlement. In Puerto Ricans (13.8%) was nearly twice the rate the society of origin, the cultural characteristics among Cuban participants (6.6%). that complement the acculturation process need When considering the aggregated Latino cat- to be addressed to understand where the person is egory, the authors found evidence in support of coming from. These characteristics will also the immigrant paradox. US-born Latino subjects establish cultural features for comparison with had significantly higher risk than immigrant the society of settlement (Gibson, 2001). In the Latino subjects for: MDD, any depressive disor- society of settlement, the orientation of the social der, social phobia, posttraumatic stress disorder environment and its citizens towards immigrants (PTSD), any anxiety disorder, alcohol depen- impacts an individual’s exposure to discrimina- dence and abuse, and drug dependence and abuse. tion in their receiving country (Gibson, 2001). In Among Mexicans, the immigrant paradox con- addition, whether or not the individual is an eth- sistently holds across mood, anxiety, and sub- nic minority in the receiving country will play a stance disorders while it is only evident among role in the acculturation process. Finally, reasons Cubans and other Latinos for substance disorders for migration play an important role in the pro- (Alegría et al., 2008). cess of acculturation. 44 D. M. Anglin et al.

Lesbian, Gay, Bisexual, binge eating disorders (Austin et al., 2009). A and Transgender Populations (LGBT) study conducted with the purpose of describing patterns of purging and binge eating from early United States (U.S.) and international studies through late adolescence in female and male consistently conclude that LGBT youth report youth across a range of sexual orientations found higher rates of emotional distress, symptoms a higher risk of eating disordered behaviors in related to mood and anxiety disorders, self-harm, lesbian, gay, bisexual, and “mostly heterosexual” suicidal ideation, and suicidal behavior when adolescents (Austin et al., 2009). compared to heterosexual youth (Russell & Fish, Similarly, suicide rates and suicidal tenden- 2016). Members of the Lesbian, Gay, Bisexual, cies among members of the transgender commu- Transgender, and Queer (LGBTQ) community nity are considerably higher compared to the have a greater risk of facing institutionalized general population. To determine the indepen- prejudice, social stress, exclusion, and rejection dent predictors of attempted suicide among trans- as well as homophobic hatred and violence gender persons, Clements-Nolle and colleagues resulting in hostile and stressful social environ- interviewed 392 male-to-female (MTF) and 123 ments that can lead to mental health problems female-to-male (FTM) individuals. Participants (Meyer, 2003). A systematic review and meta- were recruited through targeted sampling, analysis were conducted to assess the prevalence respondent-driven sampling, and agency referrals of mental disorder, substance misuse, suicide, in San Francisco (Clements-Noelle, Marx, & and suicidal ideation among Lesbian, Gay, and Katz, 2006). Results revealed that the prevalence Bisexual (LGB) individuals (King et al., 2008). of attempted suicide was 32% with depression, Results of this study revealed that the risk for and a history of substance abuse treatment, a his- depression and anxiety disorders (over a period tory of forced sex, gender-based discrimination, of 12 months or a lifetime) was at least 1.5 times and gender-based victimization independently higher in LGB people and alcohol and other sub- associated with attempted suicide (Clements- stance dependence over a 12-month period was Noelle et al., 2006). also 1.5 times higher (King et al., 2008). As illustrated in the studies above, one’s race, Another study investigating suicide-related ethnicity, immigrant status, and sexual orienta- characteristics by sexual orientation found that tion are categories of group identity that have bisexual women had a nearly six-fold increased implications for mental health outcomes. African risk of lifetime suicide attempts than heterosex- Americans are more likely to be diagnosed with ual women, and homosexually experienced men, psychosis than depression, a disparity that may defined as men who did not self-identify as LGB speak to some of the biases among clinicians that but reported same-sex sexual partners since age requires attention (Anglin et al., 2010). In addi- 18 years, had almost seven times higher risk of tion, experiences associated with acculturation lifetime suicide attempts than heterosexual men and discrimination undermine the mental health (Blosnich, Nasuti, Mays, & Cochran, 2016). In of patients of color, and it is up to clinicians to be another study conducted by Batejan and col- more open to exploring such factors that may leagues in 2015, 15 studies were reviewed have real implications for those who hold these describing associations between sexual orienta- group identities. In addition, despite the SES tion and non-suicidal self-injury in 7147 sexual challenges faced by first generation immigrants, minority and 61,701 heterosexual participants. there seems to be cultural protective factors that Results showed that sexual minority adolescents clinicians should incorporate into clinical work and bisexuals were found to be at a particularly with such patients to improve mental health out- higher risk for non-suicidal self-injury when comes. Finally, the high risk of suicide among compared to heterosexuals (Batejan, Jarvi, & LGBT youth must be considered when working Swenson, 2015). Furthermore, disparities based with patients who are exploring their sexual iden- on sexual orientation are also seen in purging and tity. Overall, different group identities raise various 4 Epidemiological Considerations Working with Culturally Diverse Populations 45 issues around the safety and overall mental health Mahalingam and Trotman Reid (2007) char- of individuals who identify with one or more of acterized intersectionality in terms of the “inter- these group identities, and it is up to clinicians to play between person and social location, with be cognizant of these risk and protective factors particular emphasis on power relations among when it comes to working with diverse patients. various social locations” (p. 45). To address issues of gender and ethnic privilege, Mahalingam and Trotman Reid (2007) organized an exchange Intersectionality of self-stories among African American college women and marginalized Dalit Indian women as In thinking about individuals who have various a technique to promote intercultural understand- group identities, it is important for them to con- ing and examine cross-cultural boundaries. The sider the concept of intersectionality. As opposed narratives produced by these women conceptual- to the addition of unique identities, intersections ized race and gender as structural categories and create unique issues, conflicts, and probabilities. social processes rather than primarily as charac- Clinicians grapple to understand how social cat- teristics of individuals. This perspective contrib- egories such as race, ethnicity, gender, sex, social uted to a more nuanced understanding of the class, sexual orientation, and many more work intersection of gender, other social identities, and simultaneously to influence outcomes. For an the power for these marginalized groups individual, the meaning of one social identity (Mahalingam & Trotman Reid, 2007). (identifying as a woman) depends on the exis- Two research studies by Mahalingam & Leu, tence of another identity (identifying as a les- and Remedios and colleagues on the intersection bian). How two, three, or four identities or of race and perceptions of masculinity illustrate groupings merge may not be as obvious because the complex nature of intersecting identities. One of differences in how an individual experiences study found that members of three different eth- levels of disadvantage or difference. nic groups (Black, Filipino, and Indian) strategi- Intersectionality can be defined as the ways in cally embraced prevailing norms of femininity in which multiple forms of inequality or disadvan- an effort to resist racial denigration (Mahalingam tage compound to create obstacles (Crenshaw, & Leu, 2005). Another experimental study found 1995). It involves trying to understand how social that when Black men were perceived as gay (pre- categories, which have so much meaning and con- sumably more feminine) participants had a less sequences in intergroup interactions, work simul- dangerous negative perception of a “black male,” taneously to influence outcomes. According to resulting in a more likable first impression Crenshaw, intersectionality is not just about hav- (Remedios, Chasteen, Rule, & Plaks, 2011). ing multiple identities, it is related to the way soci- Sinclair, Hardin, and Lowery (2006) con- etal structures make certain identities the vehicle ducted a study in which they investigated self- for vulnerability, and how institutional structures stereotyping in the context of multiple identities. play a role in the inclusion of some identities and Simultaneously run experiments examined self- exclusion of others. The intersection of individual stereotyping in the context of ethnic and gender identities is not compartmentalized wherein the identities among three samples of college stu- effects are additive, this interaction of different dents—Asian American women, European identities creates a distinct experience when com- American women and men, and African bined. Crenshaw (1995) exemplifies intersection- American women and men—each of which is ality by the double discrimination experienced by subjected to different stereotypes about math African American women; the simultaneous and verbal ability. The authors studied how they impact of both race and gender discrimination. viewed their own ability when their gender or The overlapping of racism and sexism creates a ethnicity was primed or made salient. Results unique dynamic that leads to multiple levels of showed that Asian American women and social injustice (Crenshaw, 1995). European Americans exhibited knowledge of 46 D. M. Anglin et al. stereotyped social expectancies for their more tities informs how these intersections impact salient identity. Specifically, Asian American overall mental health, which can be used to women primed with gender evaluated their ver- inform treatment. bal abilities more favorably than their mathematics abilities. But when their race was primed, they evaluated their mathematics abilities more Barriers to Effective Treatment favorably than verbal abilities (Sinclair et al., 2006). This experiment suggests that self-stereo- Not only does the intersection of certain group typing is mediated by the degree to which close identities create a unique dynamic that causes others are perceived to endorse stereotypes as multiple levels of societal injustice and stigma, it applicable to the self. also leads to group differences in treatment effec- Levin, Sinclair, Venigas, and Taylor (2002) tiveness and accessibility (Smedly, Stith, & examined the combined impact of gender and Nelson, 2003; Wang, Berglund, & Kessler, 2000). ethnicity on expectations of general discrimina- When it comes to mental illness, stigma and dis- tion against oneself and one’s group for African crimination are thought to contribute to racial and Americans, Latinos, and Whites. The double- ethnic disparities in service utilization jeopardy hypothesis states that women of color (U.S. Department of Health and Human Services, will expect to experience more discrimination 2001). For example, ethnic minorities are less than men of color, White women, and White men likely to seek outpatient mental health care than because they are part of both a low-status ethnic Caucasians, even with similar access to insurance group and a low-status gender group. services (McGuire & Miranda, 2008). In addi- Alternatively, the ethnic-prominence hypothesis tion, the literature suggests that once in treat- argues that ethnic-minority women will not differ ment, African Americans are more likely than from ethnic-minority men in their expectations of Caucasians to prematurely terminate treatment discrimination because these expectations will be (Fiscella & Sanders, 2016; McGuire & Miranda, influenced more by perceptions of ethnic dis- 2008). crimination, which they share with men of color, than by perceptions of gender discrimination (Levin et al., 2002). The researchers found that Access the study results were consistent with ethnic- prominence. Latina and African American Research has shown that differences in accessi- women did not differ from their male counter- bility to services vary by ethnic or racial group parts in expectations of personal and group dis- based on several factors. For example, despite crimination. These expectations were more expressing more favorable attitudes towards informed by the women’s perceptions of ethnic mental health services, members of racial or eth- discrimination, which they share with men of nic minority groups are less likely than color, than by their perceptions of gender dis- Caucasians to access services. African Americans crimination. In contrast, perceived gender dis- have been found to utilize fewer services than crimination contributed to expectations of Caucasians despite research that shows they are discrimination among White women, but per- more likely to recommend professional treatment ceived ethnic discrimination did not (Levin et al., options to a hypothetical person suffering from 2002). mental health problems (Anglin, Alberti, Link, & It is important to assess the degree to which Phelan, 2008). A nationally representative study various group identities are salient for patients of 583 Caucasian and 82 African American par- and the unique dynamic created in their social ticipants who responded to a vignette about a world in society. In addition, understanding the hypothetical person with major depressive disor- unique issues, conflicts, and probabilities that der, schizophrenia, or a number of physical ill- arise with the intersection of multiple group iden- nesses revealed an interesting pattern. While 4 Epidemiological Considerations Working with Culturally Diverse Populations 47

African Americans, compared to Caucasians, Olfson, & Mechanic, 2002). To a large extent, were more likely to believe that a mental health culture has been found to determine whether and professional could help individuals with schizo- to what degree an illness is stigmatized. The phrenia and major depression, they were also degree of stigma attached to an illness depends more likely to believe that mental health prob- on (1) the features of the illness, (2) how it is lems would resolve on their own (Anglin et al., symbolically interpreted by a certain culture, and 2008). Anglin et al. (2008) concluded that African (3) what effect the illness has on the individual’s Americans’ beliefs in the likelihood of remit- social identity (Fabrega, 1991). tance without professional help could undermine Stigma accompanying mental illness in their more positive attitudes toward the benefits Chinese society has been described as particu- of seeking care. Therefore, belief in the effective- larly damaging and pervasive (Tsang, Tam, Chan, ness of mental health treatment may not corre- & Cheung, 2003). A study by Kleinman described spond to an increase in service utilization among how Chinese culture plays a role in the stigmati- African Americans in the same way that this zation of individuals with Schizophrenia. belief has implication for service utilization According to Kleinman, social interactions in among the Caucasian majority (Anglin et al., Chinese groups are organized by a strict network 2008). of social relations (quanxi). The maintenance of this network is dependent on the reciprocation of favors (renqing). Returning favors is directly tied Stigma to face (mianzi), which is a representation of social power. The diagnosis of schizophrenia Stigma, an important area of study within the results in ‘loss of face’ where the stigmatized field of mental health, also plays an important become powerless to engage in social relation- role with regards to disparities in mental health ships (Yang & Kleinman, 2008). Another research outcomes (Link & Phelan, 2001). The 2001 study (Phelan, 2005) examined the sociological Surgeon General’s report on mental illness high- impact of the Human Genome Project, and spe- lighted stigma as a major impediment to receiv- cifically how this project affects the stigma of ing treatment and obtaining quality resources mental illness. Researchers interviewed 1241 (U.S. Department of Health and Human Services, participants from a number of ethnic minority 2001). Stigma is a public health concern as it may groups. They found that Chinese-Americans result in an increase in the morbidity of disease. demonstrated more socially restrictive attitudes Link and Phelan (2001) adopted a comprehensive regarding people with mental illness getting mar- conceptualization of stigma, defining it as “ele- ried and having children. Chinese-American par- ments of labeling, stereotyping, separation, status ticipants also demonstrated more intimate social loss, and discrimination that co-occur in a power distance towards siblings of people with mental situation which then allows the components of illness. Differences in attitudes towards danger- stigma to unfold” (p. 367). They argue that stigma ousness and desire to protect family sanctity does not only impact those that are already ill, but appeared to explain why Chinese-Americans also the negative attributes that our society demonstrate more socially restrictive and dis- imposes upon people with mental illness exist tancing attitudes. long before they may become patients them- The acceptance of an official diagnostic label selves (Link & Phelan, 2001). initiates two conflicting processes. It simultane- Stigma also has the ability to negatively affect ously enables treatment and care, but it also sets mental health treatment-seeking patterns into motion the stigmatizing consequences of ste- (Corrigan, 2004). Nationally representative reotyping, separation, discrimination, and power research indicates that a large proportion of peo- loss. “Excessive thinking” is an idiom for mental ple with a diagnosable mental disorder and a per- illness in the Chinese community that helps to ceived need for help do not seek help (Mojtabai, hold stigma at bay by preserving social relations 48 D. M. Anglin et al. and the moral standing of individuals. Researchers lated into a shorter life expectancy of approxi- conducted four focus groups (n = 34) with the mately 12 years for sexual minorities living in family members of schizophrenia outpatients. high-prejudice communities (Hatzenbuehler Yang et al. (2010) found that several relatives et al., 2014). admitted that denial and fear of acknowledging The intersection of race and sexual orientation mental illness motivated their use of “excessive reveals how difficult it may be for LGBT people thinking” to explain abnormal behavior. They of color to expose themselves and reach out for reported that they frequently underestimated the help. Individuals who hold these group identities severity of such deviance in hopes that their family may be more likely to be in more distressed states member’s condition would improve. This alternate when they finally make the decision to seek treat- label that evokes the universal nature of the experiment. Stigma may impede a person’s desire to ence of these psychotic-like symptoms can lead to remain in treatment and so it may be necessary to acceptance of the individuals and result in less address it directly to build the therapeutic stigma and better outcomes (Yang et al., 2010). alliance. Minority stress theory (Meyer, 1995, 2003) has provided a foundational framework for understanding sexual minority mental health dis- Conclusion parities and stigma. It suggests that sexual minorities experience distinct, chronic stressors related In reflecting back to James, described at the to their stigmatized identities, including victim- beginning of this chapter, it is important to think ization, prejudice, and discrimination. These dis- about both the macro and micro-level factors that tinct experiences, in addition to everyday may be contributing to his clinical presentation stressors, compromise the mental health and and that may shape the development of the thera- well-being of LGBT people (Russell & Fish, peutic alliance. As a second-generation immi- 2016). Furthermore, the absence of institutional- grant, bisexual, man of color, he may face stigma ized protections, biased-based bullying, and fam- and discrimination in society as well as within his ily rejection are associated with increasing these own family and community. Due to the stigma of mental health vulnerabilities. mental health treatment seeking, he may not have While prior research has shown that intraper- shared his decision to seek treatment with others. sonal and interpersonal forms of stigma nega- His odd perceptual experiences need not be clini- tively affect the health of the stigmatized, few cal psychosis and may be a component of the studies have addressed the health consequences depression. While these are all possibilities and of exposure to structural forms of stigma. To not forgone conclusions, knowledge about the address this gap in the literature, Hatzenbuehler epidemiologic research on these group identities et al. (2014) investigated whether structural and their intersections enrichens the clinicians’ stigma, defined as living in communities with perspective and shapes a different way to be curi- high levels of anti-gay prejudice, increases risk of ous about patients. premature mortality for sexual minorities. To In addition, group identity dynamics within the capture the average level of anti-gay prejudice at therapeutic dyad are often a reflection of those the community level, researchers used a repre- within the larger society. For example, racial sentative sample of US noninstitutionalized microaggressions have been found to impede the English-speaking population aged 18 and over. development of the therapeutic alliance in cross- Results revealed that sexual minorities living in racial dyads (Constantine & Kwan, 2003). communities with high levels of anti-gay preju- Microaggressions can have a negative impact on dice experienced a higher hazard of mortality the relationship between the clinician and the than those living in low-prejudice communities patient and take a myriad of forms in the clinical (Hatzenbuehler et al., 2014). This result trans- setting. For example, avoiding the discussion of 4 Epidemiological Considerations Working with Culturally Diverse Populations 49 race with a patient, or colorblindness, can be inter- Barnes, A. (2004). Race, schizophrenia, and admission to state psychiatric hospitals. Administration and Policy preted as a microinvalidation. Additionally, the in Mental Health, 31, 241–252. white therapist may make self-righteous assertions Batejan, K. L., Jarvi, S. M., & Swenson, L. P. (2015). of being non-racist; attempting to conceal unex- Sexual orientation and non-suicidal self-injury: A amined racism by identifying instances in which meta-analytic review. Archives of Suicide Research, 19, 131–150. they avow a connection with, or allegiance to, Berry, J. (1980). Acculturation as varieties of adaptation. Black people or things (Constantine & Kwan, In A. M. Padilla (Ed.), Acculturation: Theory, mod- 2003; Gelso & Hayes, 1998; Sue, Zane, Hall, & els, and some new findings (pp. 9–25). 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Ahmed Fasfous, Julia C. Daugherty, and Antonio E. Puente

A growing awareness about the role of culture in science (James, 1890; Wundt, 1863, 1912). behavioral assessment has led to the adaptation However, it is not until recently that behavioral and development of new ideas and instruments in instruments have started to address the interface understanding culturally dissimilar individuals. of culture with behavior. Cultural adaptations Yet due to a rapid growth in the scientific and and knowledge about the influence of culture on professional literature about on this emerging assessments is fundamental to ensuring that the concern, it may be difficult for practitioners to correct diagnosis can be made. There are a vari- stay informed about the latest recommendations ety of factors that may lead to inaccurate test while maintaining their clinical load and expand- interpretation, even when professionals use tests ing demographic capacity. Here we will bring to that are published and empirically supported by light a question that many practitioners may be scientific literature. Specifically, mistakes can asking themselves: are empirically supported be made when behavioral assessments do not assessments effective with culturally diverse cli- have sound psychometric properties such as: (1) ents? This question is incredibly multifaceted adequate validity (i.e., construct and conver- and complex, given that “culturally diverse” gent), (2) appropriate translations, and (3) cul- could refer to a vast range of cultures and there is turally appropriate norms that are representative a wide spectrum of clinical assessments used in of the individual being assessed. The implica- behavioral health. Nonetheless, we will under- tions of each of these factors in behavioral score some of the global concerns regarding the assessments will be outlined. In addition, sug- use of behavioral assessments with culturally gestions of how to reduce evaluation and diag- diverse populations and ultimately offer specific nostic mistakes are considered. recommendations in terms of their application. Studying the influence of culture on behavior dates back to the beginning of psychological Foundational Concepts

The goal of a behavioral health evaluation is to A. Fasfous understand the etiology, symptoms, and socio- University of Bethlehem, Bethlehem, Palestine historical context of the clinical situation as well J. C. Daugherty as of the client. Understanding the individual’s Universidad de Granada, Granada, Spain health from this multifaceted perspective sub- A. E. Puente (*) stantially reduces measurement error and leads to University of North Carolina Wilmington, more effective interventions. In this section, we Wilmington, NC, USA

© Springer Nature Switzerland AG 2020 53 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_5 54 A. Fasfous et al. address the fundamental aspects of this approach thing as fast as possible individuals from some in behavioral health evaluations while consider- cultures will be advantaged whereas others will ing the influence of culture. be penalized. In the case of the Wechsler scales, one’s perception of time is foundational to many Validity Validity is broadly defined as matching of the items being administered due to the fact the measured variable(s) to the construct that is that various tests are timed. As a consequence, intended to be understood. In other words, does individuals who come from western industrial- the test measure what it is supposed to be mea- ized cultures will obtain a higher IQ than those suring? Alternatively, are other variables poten- who do not. In recent studies conducted in Spain, tially confounding the measurement and thus significant differences were found between resulting in measurement error? Let us take the Spaniards and Moroccans in various intelligence example of measuring intelligence. If the person tests (Díaz, Sellami, Infanzón, Lanzón, & Lynn, who is being evaluated is linguistically and cul- 2012; Fasfous, Hidalgo-Ruzzante, Vilar-López, turally dissimilar to the test and/or the tester, it is Catena-Martínez, & Pérez-García, 2013). At a more likely that what is being measured is the first and superficial glance, the conclusion would difference between the two and not the intended appear obvious; individuals from western indus- construct. As a consequence, “construct irrele- trialized cultures are smarter than those of other vance” is being introduced into the measurement origins. Of course this is not the case, and serious process, resulting in a misunderstanding of how precautions must be taken so that such erroneous the person being evaluated measures up to the conclusions are not made. intended construct (AERA, APA, & NCME, A similar case is made using the specific 2014). The unintended consequences range from knowledge base from which the items are drawn. diagnostic mistakes to erroneous policies. Some examples in the Wechsler scales include Regardless of the negative outcome, the whole is that the information drawn from relies on specific simply to understand the client, their situation cultural knowledge from the USA. In one version and to effectively control any confounds that of these scales, there is a subtest that asks the cli- would result in measurement error. ent to identify what is missing or unusual in a drawing. Two examples from this one subtest A construct is defined as the concept which is include a map of the USA which excludes the meant to be understood, such as intelligence. The state of Florida, thus favoring not only residents difficulty then lies within defining the construct, from the USA but also those living in Florida. or in this example, defining intelligence. Take the Another is a drawing of snow that is missing case of measuring intelligence quotients. Using from a wood pile (presumably to be used in a fire- the Wechsler Scales as an illustration, there are place). Again, individuals living in geographical numerous assumptions that are taken into account locations where snow is more common are in the development of this test and the eventual favored. In an information scale, questions are measurement of IQ. For example, we will assume asked that again would favor individuals living in that intelligence is similar across cultures, that the USAs and even possibly from higher socio- the variables used to measure intelligence are economic groups. For example, one question similar, that knowledge about the world varies asks the name of a prominent civil rights activist, according to where one comes from, and so on. while another asks how many miles there are Accordingly, then, the use of certain variables, between New York and Paris. Would other groups such as time, become central to what an IQ is. In be favored if the question asked how many miles the case of some cultures (e.g., Hispanic and there are between Miami and Bogotá? Russian), time is less important than in industri- In sum, sometimes linguistic and cultural vari- alized western societies. Time for some is to be ables favor some groups while they penalize oth- conquered whereas for others to be enjoyed. So, ers. This occurs when we confuse the intended when intelligence is equated with doing some- construct with confounding variables, thus intro- 5 Using Empirically Supported Assessments with Cultural Minority Clients: Are They Effective? 55 ducing unwanted error in the measurement of the Pabst, & Kraus, 2011), and showed that while construct. This results in diagnostic mistakes and some countries had higher alcohol consumption provides a shaky foundation for eventual than others, they reported lower perceived intoxi- treatment. cation. The use of a subjective measure for drunk- Empirically supported behavioral assessments enness in this case was influenced by culture and may not have adequate validity when applied to was not reflective of the objective measure for individuals of other cultures and languages. This alcohol consumption. As such, while some sub- has been shown to be the case in terms of conver- jective measures may be validated and provide gent validity, a sub-type of construct validity, in useful information about cultural nuances, they which two separate measurements are similar may not suffice on their own as a measure of enough and are thus used to measure the same problematic health-related behavior. construct. Cultural biases found in the context of In terms of construct validity, measurement convergent validity can be clearly illustrated in errors arise when the latent construct that one assessment tools that are used for drinking and wishes to assess is not reflected in the items being smoking. A combination of both objective and used. A clear example can be found in intellec- subjective measures is often used to assess alco- tual quotient testing, which is often applied in hol consumption and smoking. Both methods school systems to determine which students have present particular benefits and impediments to special educational needs. Due to a lack of cul- understanding risk and severity. Drinking behav- turally adapted and translated measures, teachers ior, for example, is often thought of as something or other educational professionals may choose to that can be assessed objectively using biological apply IQ measures in English to children who are measures such as breathalyzers (i.e., breath alco- of a different native tongue. While low scores on hol content) or empirically supported self-report these tests may reflect diminished intelligence in measures for consumption frequency and quan- native English speakers, the real construct being tity. Nonetheless, these assessments do not nec- measured with non-natives may be language pro- essarily indicate whether the drinking behavior is ficiency. The consequence of these inappropriate problematic. In some cultures, it may be more applications is significant, as they can lead to acceptable to drink, or even expected due to its poor resource allocation and foment negative association with social gathering and affiliation. stereotypes. Thus, determining alcoholism solely based off of these methods would be incomplete. Subjective measures, on the other hand, may be better able Translation and Adaptation to capture nuances in cultural differences. Much of Behavioral Health Assessments of the cross-cultural literature on problematic drinking behavior stresses the importance of Accurate translations are also critical in the including measures for religion, peer and paren- interpretation of behavioral testing. Researchers tal endorsement, and motives (Kuntsche, have warned against using tests simply due to Sznitman, & Kuntsche, 2017). Despite the infor- the fact that they have been translated (Arnold & mation that subjective measures can offer, there Smith, 2013), and instead recommend verifying are also culturally specific response biases that whether translated tests have undergone a rigor- may impede clinical understanding of the behav- ous peer-review process (Paniagua, 2013). This ior’s severity. Individuals of certain cultures may is due to the fact that constructs in behavioral be prone to minimize the grade to which they health may be more subjective and susceptible to engage in or are affected by certain behaviors. cultural biases in comparison to biological This has been illustrated with subjective mea- symptoms which may be more universal. Certain sures used for alcohol intoxication. One study pitfalls can be made when translations favor the compared the perceived drunkenness between literal interpretation over semantic. Furthermore, different European countries (Müller, Piontek, even when semantic translations are made, cer- 56 A. Fasfous et al. tain constructs such as emotions may not be When translations are not available for particu- compatible or commonly expressed in all cul- lar tests, clinicians may opt to use interpreters. tures. A study conducted on the Center for Despite the fact that this may be the only option Epidemiologic Studies Depression (CES-D) available for communication between the profes- focused on the Korean translation of CES-D sional and client, additional precautions should be items and differences in performance between taken when employing interpreters for a variety of English and Korean speaking individuals (Cho reasons. First, information can be distorted through & Kim, 1998). The translation process under- the use of a third party (Musser-Granski & Carrillo, went a rigorous protocol of back translation and 1997). Issuing an interpreter may impede rapport gave precedence to semantic over literal transla- and a direct connection between the professional tion. When cross-cultural comparisons were and the patient, which may in turn affect the infor- made between the Korean and English-speaking mation the patient is willing to disclose. Second, groups, there were significant differences in the interpreter may be bilingual but not well versed response patterns between the two groups on in psychology or behavioral health. As a conse- positive emotion items. Researchers speculated quence, the interpreter may inadvertently miscon- that these differences were due to the fact that strue the message by making a literal translation as Koreans are not as likely to express certain emo- opposed to betraying the clinically relevant infor- tions such as hopefulness in a positive manner. mation (Puente & Ardila, 2000). Finally, as previ- As such, in order to compensate for these biases, ously mentioned in the case of translated material, the originally positive item “I felt hopeful” was the interpreter may speak the same language but transformed into a negative item, “I felt hope- be unfamiliar with the dialect and/or culture of the less.” Interestingly, Korean Americans with client. These noted consequences of improper lower levels of acculturation were less likely to interpretations and diminished rapport highlight report positive items than more acculturated the importance of carefully selecting adequately Korean Americans, resulting in higher scores of translated assessments. depression. Similar results have also been found among Chinese American women, who are also less likely to report CES-D items that were pre- Culturally Appropriate Norms sented in a positive manner (Li & Hicks, 2010). These findings demonstrate the importance of In terms of normative reference points, the erro- supplementing back-translations with a thor- neous application of non-representative scores ough examination of how certain constructs are often occurs due to the fact that many epidemio- expressed or experienced across cultures. If this logical instruments for behavioral health were is not done, clinicians may run the risk of over or developed in Western cultures and are based on misdiagnosing certain cultural groups. Thus, predominately white American or European while commonly used behavioral tests, such as populations. Multiple studies have demon- the CES-D, may be empirically supported and strated that applying unrepresentative scores to translated, cross-cultural equivalency must be culturally diverse individuals can lead to inac- considered. Finally, while behavioral and psy- curate test interpretations and diagnoses chological assessments may be translated into a (Daugherty, Puente, Fasfous, Hidalgo-Ruzzante, particular language, not all native speakers of & Pérez-Garcia, 2017; Norman et al., 2011). that language may understand the translation in For example, various studies that have exam- the same way. For example, in the case of the ined neuropsychological performance in healthy Spanish language, vernacular idiosyncrasies African-American participants have found vary by region and may affect how translated higher rates of impairment among African items are understood. As such, it is important to Americans when using normative scores that carefully select translated material that considers were principally developed using a sample of regionalisms and dialectical differences. Caucasian individuals (Norman et al., 2011; 5 Using Empirically Supported Assessments with Cultural Minority Clients: Are They Effective? 57

Norman, Evan, Miller, & Heaton, 2000). In sole indicator for test selection. In a recent study, response to these diagnostic errors, some Buré-Reyes et al. (2013) found differences in researchers have recommended lowering cut-off neuropsychological test performance between scores in terms of the ethnicity and race of the Spanish speakers from four different countries: examinee (Norman et al., 2000). Nonetheless, Chile, Spain, Dominican Republic, and Puerto race-dependent modifications designate race as Rico. Although all participants were native a proxy for the underlying cultural differences Spanish speakers, there were performance differ- that are at the base of discrepancies in scores. ences between the four groups in verbal memory This bias has also been found in other com- and verbal fluency tests. Considering trends monly used mental health instruments such as towards a more globalized world, the stark reality the Generalized Anxiety Disorder Test (GAD- of modern-day clinics is that the number of 7). This measure was developed and validated patients coming from different cultures far out- primarily using a Caucasian sample from the numbers the amount of tests with normative USA (65% female, 80% White, non-Hispanic) scores representing those cultures. Despite this (Spitzer, Kroenke, Williams, & Lowe, 2006). disequilibrium, clinicians can take into account One study focused on the GAD-7’s differential different variables that may affect how one item functioning (DIF), or the biases that are responds to behavioral evaluations and thus reach created when individuals of different ages, sex, a clinical determination much closer to what is ethnicities, and cultures exhibit similar levels of true for the patient. In the case of immigrants, for a trait but respond differently to measures example, clinicians may take into account factors assessing the same latent trait (Parkerson, such as bilingualism, acculturation, quality of Thibodeau, Brandt, Zvolensky, & Asmundson, education, and education level in addition to 2015). Results demonstrated lower levels of merely considering where they were born and GAD symptoms among the Black/African- their native tongue. American individuals in comparison to White/ In sum, various factors such as adequate con- Caucasians and Hispanics, suggesting that the struct and convergent validity, translations, and test may reflect lower levels of generalized anxi- representative normative scores influence the ety in African Americans than are actually expe- integrity of commonly used empirical tests. The rienced. These findings point to the major consequences of selecting culturally biased tests implications of using unrepresentative norma- are serious, lending to problems such as an tive scores in terms of diagnosis and subsequent improper allocation of resources and unsuitable treatment. treatment. The alarming rates of diagnostic errors demonstrated by the emerging research in this area indicate an urgent need for developing normative Limitation and Cautions scores that are representative of one’s background and culture. When speaking to appropriate nor- It is evident that culture shapes human behavior, mative scores, it is critical to clarify that identify- emotion, and cognition (Park & Huang, 2010; ing one’s reference group is not as simple as Van Hemert, Poortinga, & van de Vijver, 2007). determining their native language and country of Therefore, cultural variables should be consid- residence/origin. For example, should the same ered in order to provide appropriate psychologi- evaluation protocol be used to assess two differ- cal services for individuals from different ent immigrants from Thailand, one of whom has cultures. In this regard, all practitioners are lived in the USA for 40 years since age five and encouraged to become familiar with the guide- integrated well into society with another who has lines and recommendations published by the just recently immigrated and has not yet learned American Psychological Association for psy- English? Further, the simple fact of speaking the chologists who work with culturally diverse pop- same native language should not suffice as the ulations (see APA, 1990, 2002, 2003). 58 A. Fasfous et al.

The ideal practice is carried out when a practi- tures of different Spanish-speaking countries tioner assesses clients who belong to his/her cul- (Buré-Reyes et al., 2013). tural context and both speak the same language. 5. Application of various methods and tests to However, due to globalization and the increase in obtain information about the patient using the number of individuals living outside their several sources, such as parents, teachers, and homelands (United Nations, 2017), many psy- colleagues. Both quantitative and qualitative chologists are asked to evaluate culturally and approaches should also be applied in order to linguistically diverse patients. In this case, a interpret the obtained results. referral to another psychologist who speaks the 6. Finally, conscientiousness about all observed same language of the patient is preferred. If this limitations and difficulties in terms of cultural option is not available, a series of precautions issues should be noted in the final report. In may be taken to ensure that the testing being some cases, the results can be presented as a employed is adequate: hypothesis. In other words, one possibility is explaining how or why certain conclusions 1. Awareness of cultural variables (e.g., lan- were ruled out or offering an interpretation guage, familiarity with testing, quality of edu- and recommendation rather than a definitive cation, acculturation, culture of time, etc..) diagnosis. throughout the entire psychological assessment procedure, such as during the review of the patient’s history, the interview, test selec- Alternatives to Standardized tion, test administration, interpretation of Assessment results, and the final report. 2. Avoidance of literal translations and an effort In the assessment of behavior, emotion, and cog- to understand the information provided in its nition, the deviation of an individual’s behavior socio-cultural context. For example, the diag- from the normal behavior is normally evaluated nosis of social anxiety disorder in collectivist by comparing the individual’s behavior to stan- and individualist cultures is not the same and dardized norms. However, when using standard- the main symptoms of panic attacks may dif- ized assessments and tests to assess culturally fer from one culture to another (American and linguistically diverse population, we assume Psychiatric Association, 2013). For this rea- that they are similar in that the same original con- son, the DSM-V emphasizes the need to construct is being measured (Flanagan, Ortiz, & sider the socio-cultural context in the Alfonso, 2013). Making this assumption, as pre- assessment process. viously noted, may lead to the serious error of 3. Cultural adaptation of all assessment instru- committing diagnostic mistakes in the assessments. Translations and back-translations are ment process (Daugherty et al., 2017). In this not sufficient for using tests in different lan- case, the use of standardized tests is not prefera- guages. Moreover, nonverbal tests should not ble, as it may result in measurement error. be considered culturally fair tests. In some Different alternatives to standardized test may be cases, nonverbal tests may be more influenced applied. Several are described below. by cultural variables than verbal tests. The majority of diagnostic errors in psychological assessment may be explained by the misuse of Naturalistic Testing these tests in this manner. 4. Employment of specific normative data for Naturalistic testing is widely used in psychologi- each cultural group. It must be taken into cal research. It allows us to analyze behavior in a account that cultural differences are also pre- natural setting that is more reflective of the sented in sub-cultural groups, as previously patient’s reality. Naturalistic testing takes place noted in the differences found between cul- in a setting that is ecologically valid, and may be 5 Using Empirically Supported Assessments with Cultural Minority Clients: Are They Effective? 59 an alternative to standardized tests when working assessment. These barriers may be in part due to with cultural minority clients. For example, difficulties in understanding the constructs being Merrell (2001) found that naturalistic behavioral measured, the questions being posed, or other observation is the best and most adequate method related variables. One possibility for decreasing for assessing children’s social skills. The ecologi- the variability of responses is to complete collat- cal validity of this method, in addition to its sen- eral interviews. While family and significant oth- sitivity to socio-cultural contexts, confirms the ers are most likely to have knowledge of the importance of considering it in cross-cultural constructs or questions that are being pursued, behavioral assessment. The customized approach they may also have similar difficulties in com- provides increased internal validity but may be municating with the practitioner. If this is the difficult, if not impossible to replicate both within case, an ideal alternative would be to obtain and between subjects. Hence, this approach may information from sources that both understand be more useful for clinical situations with clients the client and their socio-cultural context as well that are significantly varied from the majority as of the majority group culture in which such group from which the test has been conceived constructs are understood. A common difficulty and standardized. In contrast, this approach may with these sources is that the knowledge of the produce wide variability for research purposes. person in question is often minimal if not nonexistent. As a consequence, a hybrid of both types of interviews might yield the necessary informa- Multiple Interviews tion to offer a more global understanding of the individual in their historical context, as well as If standardized procedures are untenable, one the expression of that construct within the larger possibility for obtaining reliable information is to social context, which is often the ultimate goal of complete a structured or quasi-structured inter- the evaluation. view multiple times. Completing similar interviews over time will allow for testers to know what information is maintained across time and, International Perspectives hence, could be considered as reliable and applicable to the individual in question. Of interest A difficult situation arises in circumstances where might also be to apply specific analytical assess- background information or collateral interview- ments ranging from simple word count to more ees are only available from sources that reside in complex semantic analysis. By doing so the sub- other countries. Whereas in many western coun- jective source of information becomes increas- tries clinicians often obtain information from ingly quantifiable, allowing for a more simplified multiple sources, records or collaterals, informa- assessment of words, phrases, or even the relation from these resources is often difficult if not tionship between both. This would allow for impossible to obtain for individuals from other determining what is most important using simple countries. If obtained, the constructs are dissimi- frequency counts as well as determining how spe- lar and the records are incomparable. As an exam- cific words and phrases are related to each other. ple, one could take the case of educational records, where grades are often not equivalent both in terms of individual course performance as well as Collateral Interviews across academic standings.

At times the barriers for effective communication between the client and clinician become even Multi Methods Approach greater due to a variety of circumstances, which in turn increases the likelihood of finding errors The multiple methods approach is indispensable in the qualitative information gathered during the in cross-cultural psychology. This approach 60 A. Fasfous et al. includes the combination of using quantitative text that is culturally dissimilar. However, the and qualitative methods in research and practice. literature is still far from providing confidence The mixed method could be used to obtain more that measurement error will not occur. As dis- information in behavioral assessment. The quali- cussed, there are numerous factors that compli- tative analysis of the patients’ behavior helps the cate the clinical presentation and, more practitioner to understand the behavior in its cul- importantly, the understanding of that presenta- tural context. Moreover, using different assess- tion in a larger cultural context that may inter- ment instruments and collecting data from pret culture differences as evidence of various resources (e.g., parents, friends, teachers, psychopathology. We present here a series of colleagues etc..) can help practitioners to have a approaches that would help reduce the problems more comprehensive view of the patients’ with this confound. Considering the individual problems. using multiple approaches, appreciating the limitations of the instrument(s) being employed, understanding the limitations of the comparison Starting with Psychometric Tests sample and finally being sensitive to the poten- and Ending with Socio-Cultural tial errors that might arise from an incorrect or Context incomplete understanding of the person are important steps in culturally sensitive evalua- Finally, as mentioned before, cultural differences tions. Therefore, the question in the title of this in test performance and behavioral analysis could chapter—Are empirically derived evaluations be reduced if biases are controlled. Nonetheless, effective?—can only be answered with caution. cultural differences are not limited to testing There is evidence to suggest that such evalua- issues since these differences also represent the tions can and should be pursued but there is also effect of cultural variables on the individual’s evidence that potential error can occur. Taking behavior. In addition to use culturally adapted and the suggestions provided in this chapter should adequate tests, clinicians and practitioners should reduce such an error. However, we trust that as use psychometric tests in their practices and they the literature expands and professionals as well should interpret all obtained results within the as scientists become more appreciative of the context of the patient’s socio-cultural background. complexities of evaluating culturally dissimilar As such, we suggest using a combination of individuals the potential error in measurement approaches in order to address this complex situa- will be reduced. Until then, multiple strategies tion. Specifically, practitioners should consider and significant caution should be used in evalu- using typical and standardized instruments and ating the individuals that have historically been then proceed with more qualitative approaches, misunderstood by many. finally ending with an agglomeration of all of this information presented inside a socio-historical context. By doing this, the final product becomes References an amalgamation of the western psychometric approach to those historically attached to the American Educational Research Association (AERA), Russian (i.e., Alexander Luria) approach to evalu- American Psychological Association, & National Council on Measurement in Education. (2014). ating culturally dissimilar individuals. Standards for educational and psychological testing. Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Conclusion American Psychiatric Pub. American Psychological Association. (1990). APA guide- At this junction, it appears that significant lines for providers of psychological services to ethnic, strides have been made in understanding indi- linguistic, and culturally diverse populations. Boston: viduals when compared to a larger cultural con- American Psychological Association. Retrieved from 5 Using Empirically Supported Assessments with Cultural Minority Clients: Are They Effective? 61

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Brian D. Leany

In 2002, the APA published specific guidelines to functioning, the evaluating practitioner must con- improve the delivery of mental health services we sider all systems. Thus, the practitioner cannot provide for members of non-dominant cultural merely consider the traditional etiology of groups, followed in 2003 by specific guidelines Western mental health disorder, but must familiar- for related education and training. It was guide- ize themselves with a more comprehensive under- lines four and five of the former publication (APA, standing of etiology for the culture of their client. 2002) that discussed the importance of research- Most applicable to this chapter are guidelines nine ing assessments across cultures and proper appli- and 10 that state (APA, 2017, p. 5): cation of psychometric tests for those groups, respectively. Additionally, a key construct • Psychologists strive to conduct culturally described in the 2002 guidelines was that of the appropriate and informed research, teaching, “client in context” (p. 47), that appealed for psy- supervision, consultation, assessment, inter- chologists to consider the interplay among cul- pretation, diagnosis, dissemination, and evalu- tural factors, [mental] health factors, and the ation of efficacy as they address the first four discrimination and oppression that too often levels of the Layered Ecological Model of the results. In 2017, largely based on the research and Multicultural Guidelines. practice derived from the aforementioned guide- • Psychologists actively strive to take a lines, the APA expanded the construct of “client in strength-based approach when working with context” to an “ecological approach” (as well as individuals, families, groups, communities, expanded the number of guidelines from 6 to 10) and organizations that seeks to build resil- to considering the intersection of a client’s con- ience and decrease trauma within the socio- text and identity. Key to understanding this notion cultural context. of an ecological approach to intersectionality is the utilization of a layered approach to under- Thus, it is not sufficient to merely attempt to standing is based on Bronfenbrenner’s ecological provide an accurate assessment with reasonable systems model (i.e., micro-systems, meso-sys- utility, but the mental health practitioner must tems, etc.; 1977, 1999). While the treating clini- also consider the ramifications for the resulting cian can focus more narrowly on the more diagnoses and recommendations, limiting the immediate issues of micro- and peso-system cost of said results. It is worth noting that contained within the guidelines (APA, 2017) are case B. D. Leany (*) studies [vignettes] and discussion questions that LLC, Reno, NV, USA provide opportunity to apply this process of an

© Springer Nature Switzerland AG 2020 63 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_6 64 B. D. Leany ecological appreciation for the intersectionality Ideally, the initial contact should attempt to of context and identity for the client. Finally, establish primary language, educational attain- given the emphasis on this ecological approach to ment, and the general referral problem. During context, identity, and intersectionality (hereafter this contact, the one who answers the phone referred to as “ecological approach”), and the should be able to establish whether or not the cli- emerging research with that framework, this ent is appropriate for the setting. This construct of chapter contains some reference to unpublished appropriateness may be dependent on your set- manuscripts of empirical research for evaluation ting. For example, rural settings without alterna- that considers or describes the intersectionality of tive referral resources may be more inclined to identity and context. adapt processes, while urban settings with a wider range of referral options could merely maintain a referral list and refer out. Additionally, the nature Initial Contact of adaptations that may be necessary for the evaluation including consultation, interpreters, and/or From an assessment perspective, the evaluation appropriate assessment instruments. begins when a client first reaches out for services, and that first contact with the client initiates the ecological approach to a comprehensive Intake and Psychosocial History and valid evaluation. The initial contact with your client is largely dependent upon the nature Clarifying the Presenting Problem In the of your practice, wherein both the size and scope behavioral health setting, the client may be pre- can differentially impact a critical larger institu- senting either for physical ailments that yield a tions who offer a broad scope of services, are question about mental health concerns (i.e., panic more likely to have a structure where hiring is a attack or memory complaints), or the individual centralized process that could occur outside the could be presenting with primary concerns behavioral health setting, and where non-mental related to a mental health concern (depression). health professionals are often considered inter- Regardless of the nature of presentation, a pri- changeable among departments. Thus, the indi- mary goal of this process is establishing the individual who takes your patient calls may or may vidual/family concern, while beginning the not have mental health or even healthcare experi- process of diagnostic decision making. It is how- ence (for example, an administrative assistant ever important to keep in mind that there may be for a state hospital could have recently trans- a good deal of divergence between the two. For ferred in from a non-healthcare organization). example, the family may be concerned about This is not to say that smaller organizations with poor school performance assuming a cognitive or a narrow scope of practice are more likely to learning disability, but report symptoms of ner- have individuals with mental health training vousness and avoidance more consistent with an answering the phone. The economics of a small anxiety disorder. The description of the present- private practice or non-profit may limit who can ing problem and related symptoms is very likely be hired. What is most important, regardless of to be an area where one must be most aware of setting, is that there is an appreciation for the culture idiosyncrasies in what is described as importance of this first contact with an individ- abnormal and how it is described. This can be ual seeking assessment beyond scheduling and exasperated when using an interpreter, in particu- rapport that is reflected in the individual who lar when the interpreter lacks formal training for interacts with those clients. More succinctly, if mental health constructs. that individual is not the mental health professional themselves, do they have sufficient under- Given the importance of establishing the pre- standing and training to initiate an ecological senting problem, the clinician should keep in approach for evaluation. mind that the intake is a truly reciprocal process. 6 Cultural Considerations in Psychological Assessment and Evaluation 65

It is not just a means of gathering information, individual is not completely educated in the but also one of disseminating information that USA, and from an ecological approach reflects considers the cultural background of the client. the intersection of meso- and micro-systems. For Ultimately the intake is where critical rapport and example, unless you are using a test developed the ultimate goal of the evaluation are estab- and normed for the specific educational setting lished. Specifically, the evaluator should not end (for example, a neuropsychological screener this session without having a clear understanding normed for Spanish populations with a sixth of what the client hopes to learn from the evalua- grade education used with an individual who tion as well as ensure that the client(s) have a attended school in Madrid through sixth grade), it clear understanding of what the nature and limits would not necessarily be appropriate to use the of the evaluation can provide. WIAT-III norms for an individual who started school in Mexico but has attended US schools

Establishing Cultural Identification As dis- since the ninth grade. The phrase “not necessar- cussed at the outset of this chapter, an individu- ily” is used because the presenting problem and al’s cultural identification is not as simplistic as desired goal are so important to how one ethnicity, gender, and race. This becomes further approaches the process (for example, does one complicated by the global geopolitical climate merely wish to identify what deficits exist, and technologically facilitated communication regardless of etiology, in order to assess areas of that can instantly shift that climate. Thus, cul- strength and weakness). tural identity can be influenced by static factors (like first/primary language, geographic region Socioeconomic Status Socioeconomic status, of migration, and family heritance), but also by composed of all the prior domains discussed more dynamic factors such as meso-system liv- thus far in the chapter, should be a primary con- ing circumstances or more macro geopolitical sideration for selecting and interpreting tests and shifts (such as those seen in Venezuela’s shift test batteries. As will be discussed, higher educa- from economic stability to hyperinflation and tion and greater acculturation that is more simi- Hong Kong’s move from Democratic lar to the dominant culture can increase the Commonwealth to the One-Nation, Two-System validity and utility of existing assessment instru- approach as it was returned to China). One must ments. However, the corresponding correlation consider how these shifts might influence the between fewer years of education and lesser import placed on previously held beliefs related such acculturation with decreased validity is a to socioeconomic status and cultural values primary concern that requires the evaluator to related to well-being. have a broader tool-box of assessments as well as a larger foundational knowledge about the

Pre-educational History Building on the afore- interplay among culture, identity, and the eco- mentioned cultural identification, one must con- logical application of assessment for the indi- sider the upbringing of the individual. It is vidual being assessed. important to establish how closely the individual’s pre-academic experience shaped their foundational development. For example, was a Assessments non-English language the first and primary language or was that language not allowed to be spo- If it has not been made clear to this point, it is ken in the home? Was the English spoken in the important to plainly state that the assessment home fluent? process begins with the initial contact. During that process one should have begun collecting critical information about psychosocial devel- Academic/Linguistic History Academic expe- opment, sociocultural factors, and at least a cur- rience becomes particularly interesting when an sory appraisal of current functioning. You have 66 B. D. Leany next prepared for the intake and subsequently sonality. However, research (Byrne, 2016) has collected a comprehensive psychosocial history provided empirical evidence that this is not suf- for your client. Again, the crucial issue is deter- ficient, and often carries over the inherent cul- mining what the presenting concern is and what tural bias upon which the measure was developed. steps you can take to address that question, with In the case of the former, which serves as a an ultimate goal of providing recommendations screening instrument the consequence may with a strength-based foundation that provides merely be one of a referral for further testing. resilience while limiting harm. You must then However, an inappropriate application for the lat- utilize the information gathered within the ini- ter could result in a misdiagnosis for disordered tial contact and psychosocial history to prepare personality, which is serious in and of itself, but an evaluation that is appropriate for your client could be exponentially more problematic if the and maintains fidelity for the selected tests, application were to occur as part of a forensic or while at the same time adhering to the APA’s pre-employment screening evaluation. Thus, one practice guidelines. Broadly, much has been must carefully consider the validity and utility of said about the process and evaluation across cul- the measure(s) being selected beyond its avail- tures (Benuto, 2013; Benuto & Leany, 2015; ability in the relevant language. In fact, nearly Benuto, Thaler, & Leany, 2014). Consistently, two decades ago Sue (1999) posited that sour considerations for language, educational attain- practice of psychology failed to consider the ment, and socioeconomic status were discussed intersectionality [using the language of the cur- as positive predictors of adaptation for existing rent APA framework] of global, cultural, and eth- assessment practices and resulting utility. nic factors, which Sue described as classic threats However, when any one area for an individual is to validity, preferring instead to engage in prac- observed to be more disparate from the US nor- tices that fail to appreciate those threats. Sue mative sample(s), the more one must consider (1999) and later Arnett (2008) appropriately rec- the intersectionality among social cultural fac- ognized that outright ignorance or even a mere tors for that individual. Additionally, and most lapse in evaluating the intersectionality [again relevant to this section, is the utilization of using the APA, 2017] framework could alter the existing assessment instruments. When choos- constructs and application of scientific theory in ing an assessment instrument, one logically first a way that rendered them meaningless and pos- selects the domain of interest (i.e., personality sibly harmful. or IQ), but next must evaluate psychometric properties such as the normative sample, reli- Reliability, Validity, and Utility These con- ability and validity. structs are the foundation of assessment, especially when utilizing tests (or questionnaires) to provide objective support for a diagnosis, prog- Psychometrics nosis, treatment recommendations, or an expert opinion (in the case of forensic evaluations).

Normative Considerations Given the expan- However, when evaluating an individual who was sion of guidelines to consider the global context not included in the normative group used to of the individual culture, and the primacy of lan- establish those constructs, they lose their mean- guage as a barrier to psychological assessment, ing. Considering validity, when evaluating an one may be tempted to adopt a strategy of using individual who is not represented in the norma- familiar measures that have been translated into tive sample, one can at best describe how closely the client’s language. Indeed measures such as that individual’s data compares to that of the the Montreal Cognitive Assessment (MoCA; dominant culture. However, one could not sug- Nasreddine et al., 2005) used for the screening of gest that someone born and raised in Jutiapa dementia has been translated in to several lan- region of Guatemala has an intellectual disability guages, as have the MMPI assessments of per- (for example) based on the Wechsler Adult 6 Cultural Considerations in Psychological Assessment and Evaluation 67

Intelligence Test normed on a US normative sam- populations may be shifting or were previously ple. Even considering that the test is available in misunderstood (Benuto, Zimmerman, Casas, Spanish, linguistic and even visuospatial domains Gonzalez, & Newlands, Submitted for Review). of the assessment are unlikely to accurately Thus, even within this narrow category of a reflect the cultural norms of Guatemala as a depressive mood disorder, one can appreciate whole. Further, the construct of intellectual the challenging and dynamic nature of the eco- capacity is one of innate stability (reliability). logical approach to assessment. Thus, such a diagnosis is likely to yield improper recommendations for intervention. In fact, Mood Disorders The aforementioned difficul- researchers (Duggan, et al., 2018) have recently ties with evaluating symptoms within this diag- identified regional discrepancies for normative nostic category reflect the challenges in applying groups who share a common language (Spanish) dominant culture norms across more homoge- that would relatively inflate or conversely under- nous cultural groups. There are a wide range of estimate scores with meaningful interpretive dif- translated measures that assess for depression, ferences. This reflects the dynamic nature of but it is unclear if they accurately capture a func- multicultural assessment research and the need tional impairment related to the construct of a for evaluators to be proactive in improving their depressive mood episode. This is not to say that knowledge for tests and the ever-evolving empir- the clinician should eschew those measures as a ical data related to their psychometrics when method of narrowing the diagnostic decision applied to specific cultural groups. However, making process. Rather, the practitioner can use researchers argue that bias is not necessarily dis- these measures as tools to weigh possible diagno- criminatory (Reynolds & Suzuki, 2012), and that ses, while maintaining an awareness of culturally some bias may actually inflate scores of individu- unique idioms and beliefs that may alter the ulti- als that are not represented in the normative mate diagnostic classification. For example, the sample(s) of a test. Thus, in addition to recom- constructs of Marianismo and Fatalismo identi- mending an evaluation of the psychometric prop- fied in Latinx cultures (Bridges & Anastasia, erties and bias of a specific test, these researchers 2016) may be misconstrued as a dysthymic con- encourage evaluators to also evaluate additional dition, rather than a culturally bound acceptance threats to validity such as bias of the referring that family is of greater importance than the indi- source and using a multi-method/ability approach vidual and suffering is an expected part of life (as to testing. balance rather than enduring pessimism), which may be functionally healthy (e.g., there is a ben- Domains of Assessment Our diagnostic sys- efit at the end of suffering that is also part of life). tem itself creates challenges for application Thus, when clients express seemingly pathologi- across cultures. This is because there is a high cal statements, the evaluator must probe the degree of variability among cultures in both extent and course of those beliefs (e.g., is there an subjective and objective appraisals of what con- end point or a benefit to the individual or the fam- stitutes a symptom of mental illness, and those ily group?). appraisals can be further influenced by acculturation. For example, researchers investigating Anxiety Similar to the diagnostic classification depression in Asian cultures have observed that of mood disorders, attempts to assess and classify individuals who demonstrate high acculturation anxiety disorders can be difficult. This difficulty for Asian collectivism are more likely to is often due to the variability in culturally unique endorse somatic symptoms related to depres- descriptions of symptoms that would appear on sion (Chang, Jetten, Cruwys, & Haslam, 2017). their face to represent a frank symptom, but upon However, the results for studies evaluating further consideration, may actually reflect distinct symptom expression for depression in Latinx experiences and cultural idioms. For example, 68 B. D. Leany researchers (Benuto, Zimmerman, Gonzalez, & available in multiple languages. Thus, the use of Corral Rodriquez, In Preparation), when evaluat- a Spanish translation of the MMPI-2-RF might ing the factor structure of the BAI with Latinx seem a logical undertaking for the assessment of respondents, discussed the seemingly straightfor- disordered personality and clinical syndromes ward interpretation of an Ataque de nervios as a for a client whose primary language is Spanish. panic attack, may merely represent typical sys- However, this application does raise concern. temic stress within a family or social system. Firstly, the normative sample for this test is not Thus, clinicians need to ensure that they are fol- one that was necessarily represents the ecologi- lowing-up on questionnaires such as the BAI, ask- cal approach set forth in the APA’s guidelines ing about behavioral quality and functional (2017). impairment. For example, one should assess for physiological arousal and related impairment in Neurocognitive The process of neurocognitive social, occupational, and/or educational domains. assessment is one of inferring brain injury, dis- Does an individual reporting an Ataque de nervios ease, or congenital defect by means of corre- present for medical care or leave work to seek sponding observed behavior to our knowledge of medical care? cerebral physiology. This processes may however yield some unexpected bias in the assessment Psychosis Psychosis has serious, long-term process. For example, one may assume that there costs economically as well as for the micro and is a great deal of homogeneity in neuroanatomy macro societal systems (Evensen et al., 2015). and thus cognitive functioning. For example, the Further, research has shown that youth, in par- lateralization of motor control (contralateral con- ticular, of non-dominant ethnic groups are more trol) and localization of vision in the occipital likely to have psychotic symptoms that have a lobe are well-documented. However, even the lat- greater negative effect than their non-minority ter is subject to environmental influences, as evi- peers (Henderson, 2017). However, research denced by the recruitment of the occipital lobe has shown that early intervention for psychosis for tactile processing of language (reading can bring down the economic cost and improve Braille) in previously sighted individuals has the long-term prognosis for individuals diag- been shown to occur (Katarzyna et al., 2016). nosed with psychotic disorders (Aceituno, Vera, Additional research has shown the impact of Prina, & McCrone, 2019). Conversely, research bilingualism on brain organization, for both has shown that African Americans are over- regionalized gray and white matter volume for represented in psychiatric in-patient settings functions of language and executive function (Snowden, Hastings, & Alvidrez, 2009). (Gasquoine, 2016)Thus, the environment plays Further, an African American presenting with an important role in neurological organization, OCD or atypical symptoms are more often and through one may be fluent in both the lan- diagnosed with psychosis (Hollander & Cohen, guage of assessment, fluency in another language 1994; Ninan & Shelton, 1993). Thus, it is (in particular one’s primary language) impacts imperative that the clinician providing assess- the validity of norms that do not include a repre- ment is aware of cultural and socio-demo- sentative sample of bilingual individuals in the graphic prevalence rates. normative group.

Personality When a mental health evaluator As inferred by the preceding section, the likely considers assessment of personality, in particu- most obvious cultural difference in observable lar disorders of personality, it would be surpris- cognitive behavior is that of language, and it has ing if the Minnesota or Millon inventories were been shown that in addition to years of education, not primary in consideration. This is especially there is a positive correlations between English true when one considers that both systems are language proficiency and the application of US 6 Cultural Considerations in Psychological Assessment and Evaluation 69 testing norms (Benuto, 2013; Benuto et al., 2014; well as how culture impacts the testing environ- Benuto & Leany, 2015). Thus, one may be ment; have an awareness of multicultural assess- inclined to utilize an interpreter or identify ment tools and evaluation techniques, and the assessments that are seemingly language neutral. benefits as well as the pitfalls of using an inter- However, the former practice (specific to neuro- preter in testing (Lanca & Wilner, 2019). psychological assessment and the WAIS) has demonstrated that such practice can increase Learning Disability While learning disability variability of scores within domains, while at the can be identified within the broader category of a same time creating a discrepancy that is differen- neurocognitive assessment, it warrants a separate tial biased towards improved language without a discussion within the context of cultural consid- corresponding change in non-verbal domains erations. This is because learning disability is (Casas et al., 2012). The latter use of seemingly most relevant in the educational context. language neutral tests fails to consider the inter- Education is a culture bound process, which action of identity, culture, and context. Ardila reflects a process of indoctrination by the culture (2018) has also identified that educational attain- providing the education. That process also ment, across cultures, is a primary predictor of reflects a good deal of information about the cognitive performance on neuropsychological broader construct of socioeconomic status, and tests. However, this research further describes the reflects the intersectionality of cultural context function of language (both oral and written) as a and identity. Thus, the evaluator must begin to proxy for cognitive (e.g., the positive correlation question several things that might otherwise be between literacy and cognitive abilities), and the assumed within the US framework. discrepancy for visual-spatial abilities among cultures. Thus, the researcher posits that cultur- First, in that questioning of assumptions is the ally specific norms are a critical element to valid expectancy for participation in the educational neuropsychological assessment across cultures. process. Specifically, does the individual’s cul- Further, research on the functional failure to ture or country of origin require compulsory edu- apply culturally appropriate norms has shown cation or is it something generally available to that it can result in misdiagnosis (even among only those who have the luxury of sending their seemingly homogenous groups) at a rate of one children to school rather than engaging them in in five (Daugherty, Puente, Fasfous, Hidalgo- work to support the family? Next, one must con- Ruzzante, & Pérez-Garcia, 2017) sider the average number of years for participa- Attempts have been made to develop neuro- tion in education (e.g., is a high school diploma psychological test batteries that are more cultur- or equivalent the norm). Finally, one must con- ally inclusive (Akshoomoff et al., 2014). sider the number of years within systems. One is However, while an improvement, these tests still likely to have an individual who began their edu- yield psychometric deficiencies. For example, cation in one country and has continued in the the use of the NIH-TB-CB has demonstrated USA. Thus, consideration should be made for the poorer fluid reasoning abilities for Spanish speak- validity of the traditional application of differ- ers, but better vocabulary performance for those ences between intellectual capacity and achieve- same individuals born outside the USA (Flores ment as an indicator of a learning disability. Such et al., 2017). Thus, even when utilizing batteries a discrepancy may instead reflect an individual that are developed for more heterogenous groups, who is delayed in crystalized knowledge for edu- an evaluator must invest in a critical appraisal of cational domains rather than a true learning dis- the benefits and limitations of a particular battery. ability. This is especially true when the Further, it has been suggested that even when uti- discrepancy identified is that of language (given lizing these measures, clinicians must be cogni- the broader homogeneity for math across cul- zant of: psychological factors that impact tures). In these instances, one should consider evaluation of more heterogenous populations, as collateral information for academic performance 70 B. D. Leany prior to US enrollment or, when possible, cultur- while acknowledging the flaws in that process. ally appropriate achievement tests (such as the He does for example, suggest that the utilization Woodcok-Munoz tests for Spanish speaking indi- of a multipoint (chronologically) assessment can viduals). Though much discussion has been made improve the accuracy and utility of the measure. here about the appropriateness of a learning dis- However, this does not seem to adequately ability diagnosis, the clinician may want to con- address the inherent cultural bias contained in sider the utility of the evaluation. Specifically, those measures as well as ignores the subjectivity regardless of etiology, when a discrepancy exists of psycho-legal constructs, which may be magni- one should consider how recommendations for fied when evaluating an individual whose cul- intervention would improve the individuals func- tural identity and context may not reflect the tioning. For example, a student who demonstrates same values held by the US justice system. a discrepant achievement for reading comprehen- Additionally, it seems to introduce additional sion as compared to their verbal intellect is likely subjectivity, to the extent that some states even to benefit from specific instruction to improve appear to have contradictory perspectives when comprehension regardless of the learning disabil- applying the same measures (for example, the ity diagnosis (assuming it is not attributable to a disparity between California and Texas utilizing developmental disorder). identical measures of risk; Leany & Benuto, 2019), wherein, depending on the jurisdiction,

Forensic The forensic setting introduces addi- one may deem the threats to validity to be within tional complexity at the nexus of psychological an acceptable range in the name of justice, while and legal constructs such as competency, capac- the other finds the same threats to be unjust and ity, criminal responsibility, and risk. Given the overly punitive. Ultimately, the evaluator (identi- implications for civil liberties (including the fied by the courts as an expert, qualified to pres- application of capital punishment), cultural con- ent such expert opinions) should weigh the siderations within the forensic setting should give potential costs (such as capital punishment or a the evaluator the greatest amount of pause, not determination of child custody) against the only for the consequences, but also due to the strength empirical data and psychometrics for the overrepresentation of minority groups (compared culture context and identity of the individual to population data) in the legal setting (Moore, being evaluated. For instance, would one feel 2017). As with other domains of assessment, confident in opining for the court that a recent translators (Wagoner, 2016) and the use of stan- immigrant had sufficient intellectual capacity to dardized measures (for example, those of risk be executed for a capital crime, based on the nor- and needs of offenders; Olver, 2016) have been mative and psychometric data for the tests used to suggested. The former discusses appropriate establish that capacity? caveats of providing evaluations with non- English speakers, even when the evaluator speaks the language, but ultimately still suggests that Findings and Recommendations proper preparation by the evaluator may help ameliorate the pitfalls of such an evaluation. This The purpose of assessment is, of course, to move preparation seems however to be inadequate, the client towards resolution of the presenting including literal translations of a standardized problem through diagnostic classification and measure and a reliance on the interpreter’s identi- corresponding recommendations for intervention. fication of cultural considerations for the When discussing interventions, researchers argue responses for the individual’s responses. Olver that decreasing health disparities and improving (2016) addresses the use and adaptation of stan- outcomes for ethnic subcultural groups require dardized measures of needs and risks, in a man- cultural adaptations (Barrera, et al., 2013). While ner more consistent with the APA’s previous other researchers have identified treatment some guidelines for cultural considerations (2002) universality for treatment modality (i.e., CBT) 6 Cultural Considerations in Psychological Assessment and Evaluation 71 across cultures (Benuto & O’Donohue, 2015; appropriate measures and) to yield assessments Benuto, O’Donohue, Bennett, & Casas, 2019), that are in keeping with the APA’s guidelines for and further argued that the presumption of need an ecological approach to context, identity, and for adaptation is based on stereotypical beliefs. intersectionality. Thus, it is incumbent upon the However, one may argue that the translation of an evaluator to discuss the limitations that remain at intervention to another language is an adaptation. the conclusion of the assessment process, espe- Addressing what constitutes adaptation, research- cially when those limitations also have a high ers have attempted to develop a more universal cost (i.e., evaluations that impact the civil liber- consideration for adaptation that can aid in ties of an individual). Diagnoses and recommen- research to develop and evaluate adaptations dations for intervention therefore must reflect an (described as the Cultural Treatment Adaptation understanding of the interaction among the lay- Framework or CATF; Chu & Leino, 2017) by cat- ers of functioning and reflect the strength-based egories such as core therapeutic components as approach described in the APA’s guidelines opposed to peripheral components as well as eval- (2003), while limiting trauma. Finally, as practi- uating intervention without adaptation. Ultimately, tioners it is incumbent upon us to not only adhere like the process of evaluating inclusion of tests for to the guidelines set forth by the APA but to an assessment battery, the clinician should be attempt to improve upon them when possible. aware of the research (or lack thereof) for intervention related to the cultural group with which the client identifies. Further, the clinician should References keep in mind the five General Principles of the APA Code of Ethics (APA, 2016), evaluating the Aceituno, D., Vera, N., Prina, A. M., & McCrone, P. findings and recommendations within the context (2019). Cost-effectiveness of early intervention in psychosis: Systematic review. The British Journal of of those principles and the current guidance (APA, Psychiatry, 215(1), 388–394. 2017) with regard to multicultural practice. Akshoomoff, N., Newman, E., Thompson, W. K., McCabe, C., Bloss, C. S., Chang, L., … Gruen, J. R. 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Revision of ethical standard 3.04 of the “ethical principles of psy- dominant culture in the behavioral healthcare chologists and code of conduct” (2002, as amended setting, will require additional education, train- 2010). The American Psychologist, 71(9), 900. ing, and practice. A solid step in that direction is American Psychological Association. (2017). seeking out resources such as those provided in Multicultural guidelines: An ecological approach to context, identity, and intersectionality Washington, this text, yet this remains a dynamic and evolving DC: Author. process. Ardila, A. (2018). Culture and cognitive testing. In The evaluation of individuals who are not Historical development of human cognition (pp. 135– members of the dominant US culture remains an 159). Singapore: Springer. Arnett, J. J. (2008). The neglected 95%: Why American improving, but imperfect process. Evaluators psychology needs to become less American. 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Joanne Qinaʻau and Akihiko Masuda

Background: The Emergence across therapies, a combination of these, or of Common Factors Theories something else entirely. The therapies du jour Rosenzweig refers to At last the Dodo said, ‘Everybody has won, and all were those based upon theories of personality must have prizes.’ (Rosenzweig, 1936); he names psychoanalysis, Christian Science, and Pavolov’s behaviorism in And with Rosenzweig’s first reference to the this first commentary on common factors. By his absurdity of the Caucus race from Alice in estimation, there were three considerations which Wonderland (Rosenzweig, 1936), the great applied to all of these therapies and accounted for debate around common factors made its debut in success: the psychotherapy and behavioral health literature. In the classic C.S. Lewis tale, the dodo bird 1. the operation of implicit, unverbalized factors, initiates a race so those in attendance might have such as catharsis, and the as-yet undefined an opportunity to dry themselves off, with no effect of the personality of the good therapist; defined rules, nor direction, nor finish line. When 2. the formal consistency of the therapeutic ide- the race is—rather arbitrarily—called to an end, ology as a basis for reintegration; and, he proclaims that all participants have won and 3. the alternative formulation of psychological deserve to receive prizes. Rosenzweig uses this events and the interdependence of personality scene to bring life to the notion that therapies of organization as concepts which reduce the his day all “win,” in terms of patient outcomes. effectual importance of mooted differences By this he meant that there was no true way of between one form of psychotherapy and knowing whether the salutary outcomes observed another. in clients were attributable to a given therapy’s unique qualities, to some set of shared qualities Though the conceptualization of common factors morphed over time, these were the germina- tive seeds that were planted for several decades J. Qinaʻau of dialogue to follow. In his positioning of psy- Teachers College, Columbia University, chotherapy as a problem in learning theory, New York, NY, USA Shoben (1949) asserted two “common tools” A. Masuda (*) found across all forms of psychotherapy: the rela- Department of Psychology, University of Hawai i at ʻ tionship and conversational content. Black (1952) Mānoa, Honolulu, HI, USA e-mail: [email protected] then went so far as to blame psychologists’

loyalties to certain psychotherapeutic approaches meta-analyses have generally or partially con- for limiting the field’s potential for discovery in firmed the Dodo Bird Verdict, though some con- what he deemed to be the true mechanism for tend that the very nature of randomized controlled change, “the interpersonal relationship itself.” trials—and the meta-analyses on which they are According to Black, rapport, acceptance, and based—are inappropriate methods of study for relational efficacy were at the heart of this con- the question of therapeutic difference in effect ception of the therapeutic relationship. Albert (see Budd & Hughes, 2009; Seligman, 1995). Ellis, one of the founders of the modern day cognitive behavioral approach, included, in his 1955 account of the 26 qualifications of the therapist, Theories of Common Factors Today acceptance of the client as a person, despite their shortcomings, “real warmth, kindness, and love” More recently, common factors have been posi- toward the client, and an ability to establish tioned not only as a group of impactful phenom- “excellent rapport” so the client might easefully ena typically found in therapy, but as parts of a share their “innermost secrets” (Ellis, 1955). The defined theoretical model explicating mecha- list goes on and is a fascinating peek into his view nisms of change in psychotherapy (e.g., Ahn & on the role of subjective person-centered quali- Wampold, 2001; Wampold, 2015). One notable ties essential to a successful therapist. theory of common factors today is Wampold and Imel’s contextual model of common factors (Wampold, 2015; Wampold & Imel, 2015), which Evidence of Dodo Bird Verdict is different from the perspective of contextual behavioral science (CBS; Hayes, Barnes- Forty years after Rosenzweig’s first dodo refer- Holmes, et al., 2012) that we present below. ence, Luborsky, Singer, and Luborsky (1975) Wampold’s contextual model identifies eight presented a qualitative review on the first com- common factors, in order of effect size: goal con- parative psychotherapy Dodo Bird Verdict by sensus or collaboration, empathy, therapeutic examining various forms of psychotherapies alliance, positive regard, congruence or genuine- across 33 studies. They concluded that there ness, therapist factors, cultural adaptation, and existed only insignificant differences across these expectations (Wampold, 2015). The model views psychotherapies in proportions of patients who these factors as instrumental parts of major path- improved, and cemented the notion of the Dodo ways of change in the inherently interpersonal Bird Verdict as a controversial claim that regard- process of therapy. These pathways are: (a) the less of unique techniques or theoretical frame- real therapeutic relationship, (b) expectations, works, all psychotherapies will result in and (c) specific ingredients (i.e., aspects of a comparable effects. Around the same time, the treatment that work particularly well for a par- first quantitative meta-analysis was conducted to ticular client). explore the differences in efficacy across thera- Wampold and Imel (2015) further argue that, pies (Smith & Glass, 1977). This meta-analysis before any of these three pathways takes form, suggested that the Dodo Bird Verdict did indeed the initial bond between the client and therapist hold true under a quantitative lens, which were should be solid. It is in this section of the model subsequently supported by Shapiro and Shapiro in which the common factor of therapeutic alli- in their 1982 meta-analysis (Shapiro & Shapiro, ance is most elaborated upon. However, calling 1982). upon Ed Bordin’s (1979) depiction of the In the decades that followed, many studies, uniquely deep bonds of trust and attachment in meta-analyses, and meta-meta-analyses would therapy, the authors position therapeutic alliance go down the same rabbit hole (e.g., Horvath & as foundational to all the three pathways. Once Symonds, 1991; Luborsky et al., 2002; Marcus, the bond is formed, the real therapeutic relation- O’Connell, Norris, & Sawaqdeh, 2014). Most ship can begin to take shape. A real therapeutic 7 Functional and Contextaul Account of Common Factors 77 relationship is defined by the common factor of and perhaps the newest addition to the list of genuineness (i.e., authenticity, openness, and common factors is cultural adaptation. “Culture honesty)—with the common factor of empathy at and context are inextricably blended with all the core of this process. As the authors of the con- aspects of the therapy enterprise,” according to textual model note, therapist empathy ratings are the contextual model (Wampold & Imel, 2015). one of the most reliable predictors of psychotherapy outcomes (e.g., Elliott, Bohart, Watson, & Greenberg, 2011). Positive regard and therapist Rapport and Rapport Building factors are the third and fourth common factors in Contemporary Common Factor associated with this pathway. Models The second pathway of expectations, also conceptualized as a common factor, is formed Among a wide range of common factors, thera- through explanations of the treatment by the cli- peutic alliance is the most extensively studied ent, and through treatment actions. Psychotherapy behavioral phenomenon in psychotherapy provides an account of the client’s mental health (Wampold, 2015), and very closely related to this that positions the alleviation of their suffering as concept is rapport. Healthy rapport is the harmo- achievable, given a set of steps and activities. In nious relationship or bond between a client and doing so, the client’s expectations of success are therapist framed by understanding, trust, and heightened. In the contextual model, what is key open communication. In and of itself a “powerful for creating expectations is not the epistemologi- therapeutic factor” (Hathaway, 1948), rapport cal validity of a theory, but whether or not the involves aspects of all the common factors. More explanation of the disorder is accepted by the cli- specifically, the proponents of common factors ent, and if actions in therapy are consistent with theories argue that genuineness, empathy, posi- the explanation. The common factors of thera- tive regard, and cultural adaptation can lead to pist influence and goal consensus would logi- better rapport, while alliance and collaboration cally play into this pathway, though they are not might be enhanced if rapport has already been explicitly called out in the description provided established. Using empathy, one might establish by Wampold and Imel (2015). While expecta- stronger rapport, and when rapport is solid, mutu- tions alone have been found to have salutary ally agreed upon goals and expectations become effects on symptom outcomes, expectations as much easier to arrive upon. Goals and expecta- conceptualized here require “the systematic use tions will ebb and flow throughout the course of of some set of specific ingredients, delivered in a therapy and rapport can be powerful leverage in cogent and convincing matter to the client and helping the client better align expectations with accepted by the client,” positioned as both a value-based goals and behaviors. common factor and the third pathway in the con- The terms, therapeutic alliance, therapeutic textual model. relationship, and rapport are sometimes used Specific ingredients, the third pathway in the interchangeably. The literature is rich with evi- model, are those treatment actions which elicit dence of therapeutic alliance supporting better change and ultimately correct the client’s par- outcomes in PTSD (Cloitre, Chase Stovall- ticular symptoms. These actions specifically tar- McClough, Miranda, & Chemtob, 2004), depres- get some aspect of psychopathology, and are sion (Krupnick et al., 2006), alcoholism more broadly defined by the client engaging in (Connors, Carroll, DiClemente, Longabaugh, & activities that promote wellbeing or attenuate Donovan, 1997), and non-chronic schizophrenia suffering. It is these effects that would not be (Frank & Gunderson, 1990). In studies with considered “general effects,” not part of the medical patients, strong rapport is associated common factors. with minimized defensive attitudes, more accu- Finally, with six of the seven common factors rate diagnoses, and fewer malpractice suits accounted for in the contextual model, the last, (Eastaugh, 2004). 78 J. Qinaʻau and A. Masuda

In the 2018 issue of Psychotherapy (e.g., models such as the contextual model postulate Norcross & Lambert, 2018), the American key mechanisms of therapeutic change, such as Psychological Association (APA) Task Force therapeutic relationship, expectation, and spe- on Evidence-Based Relationships and cific treatment ingredients, through which psy- Responsiveness outlines the depreciation of the chotherapy produces its benefits, while therapeutic relationship in modern treatment conceptualizing common factors as part of these guidelines and evidence-based practices. In the mechanisms. The contextual model has been issue’s 16 articles, meta-analytic methods are many decades in the making and is presented used to illustrate the links between relationship with great benefit to students, therapists, elements and treatment outcome. A consensus researchers, and allies in behavioral health and of experts deemed 9 of the relationship ele- wellbeing. As we will present below, seeing the ments as “demonstrably effective”: alliance in relationships between pathways of therapeutic individual psychotherapy; alliance in child and change and common factors through the lens of adolescent psychotherapy; alliances in couple CBS offers even greater nuance and structure and family therapy; collaboration; goal consen- that can serve to inform improvements upon our sus; cohesion in group therapy; empathy; posi- approaches to treatment. A CBS approach tive regard and affirmation; and collecting and assumes that therapeutic relationship and thera- delivering client feedback. A further 7 elements peutic procedure are inseparable as both reflect of relationship were found to be “probably the act of therapist in a context, the act of client effective”: congruence and genuineness; real in a context, and the interaction of the two in a relationship; emotional expression; cultivating context (Hayes, Villatte, Levin, & Hildebrandt, positive expectations; promoting treatment 2011; Masuda & Rivzvi, 2019). credibility; managing countertransference; and Furthermore, a CBS perspective provides the repairing alliance ruptures. Finally, in terms of guiding theories of behavioral health and behav- methods of adaptation, culture (race and eth- ior change that are applicable to a broad range of nicity), religion and spirituality, and patient clinical and applied cases in various sociocultural preferences were found to be “demonstrably contexts (Hayes, 2005a; Hayes, Long, Levin, & important” for effective therapy. Follette, 2013; Masuda & Rivzvi, 2019). A lack In sum, the consensus is that the psychother- of these guiding theories is devastating in theory apy relationship “makes substantial and consis- and practice (Hayes, Luoma, Bond, Masuda, & tent contributions to outcome independent of the Lillis, 2006; Klepac et al., 2012; Mennin, Ellard, type of treatment” (see Norcross & Lambert, Fresco, & Gross, 2013). Without common lan- 2018 for the task force’s formal conclusions and guage and theory, progress toward the shared recommendations). Each element of the thera- goal of alleviating human suffering is deceler- peutic relationship explored by the expert task ated. Following the framework of contemporary force informs and is informed by rapport. common factor models, goal consensus, alliance, empathy, and positive regard and affirmation are viewed as common factors only when they serve Critiques of Contemporary Common as a means to or are the reflection of behavioral Factor Models health and wellness (Wampold, 2015). Without clearly stated models of what behavioral health is Across the history of psychotherapy and behav- and how to promote it (i.e., behavior change), ioral health, common factor models such as the there is no way for us to adequately conceptual- contextual model have emerged as an alternative ize whether a given behavioral and interpersonal to the medical model that primarily focuses on phenomenon that unfolds in therapy is therapeu- specific treatment techniques and ingredients tic, to evaluate whether a given therapeutic work (e.g., Norcross & Lambert, 2018; Wampold & reflects the heart of these key common factors, Imel, 2015). Contemporary common factor and to systematically adjust and promote thera- 7 Functional and Contextaul Account of Common Factors 79 peutic work. To this end, we present the broad home that integrated Japanese, Hawaiian, and concepts of cultural considerations and rapport Portuguese family values and she identifies below, elaborate upon the contextual behavioral strongly with the Hawaiian approach to warm scientific perspective, and provide commentary open communication. She was taught the skills on how one might approach culture and rapport involved in the more subtle and reserved form of through this lens. Japanese communication, though she only utilizes such an approach with certain members of her family or in particular social circumstances. Culture and Cultural Considerations How might a clinician use this information to in Establishing Rapport optimize rapport? Psychotherapy itself is a cultural phenomenon that plays a vital role in the Although contemporary theories of common fac- treatment process (Bernal & Scharró-del-Río, tors include cultural adaptations of treatments 2001). As such, a dynamic functional and contex- (Wampold, 2015), the literature of common fac- tual approach, one which may incorporate, but tors and that of cultural considerations remains does not require, specific elements of content, somewhat disjointed. Further, if healthy rapport warrants exploration. requires understanding and trust, it stands to reason that cultural considerations will play a crucial role in the formation of rapport. To understand Current Frameworks for Considering the role of cultural considerations in rapport Culture in Client Relationships building and the therapeutic relationship, it may be best to start with reviewing our understanding In this section, we will present three major of culture. frameworks that are currently used for consid- Definitions of culture vary across disciplines ering culture in the therapeutic relationship. and moments in time. Nevertheless, in the field of These are (a) the ADDRESSING model by behavioral health, culture is generally viewed as: Hays (2008); (b) the model of cultural compe- A dynamic process involving worldviews and tence by Sue and Sue (2016); and (c) the guide- ways of living in a physical and social environment lines provided by the American Psychological shared by groups, which are passed from genera- Association, Multicultural Guidelines: An tion to generation and may be modified by contacts Ecological Approach to Context, Identity, and between cultures in a particular social, historical, and political context. Cultures vary on a continuum Intersectionality (APA, 2017). of interconnection from independence (i.e., inter- The ADDRESSING framework for clinicians nally homogeneous) to interdependence to com- and counselors guides psychologists working plete dependence on other cultures. The latter two with clients in identifying key intersectional forms are hybrid cultures, which probably constitute the majority in our global community (Whaley aspects of identity (Hays, 2008). These are age, & Davis, 2007). developmental and acquired disabilities, religion, ethnicity, socioeconomic status, sexual orienta- From this perspective of culture, knowing about a tion, indigenous heritage, national origin, and client’s self-identified culture does not equate to gender. Making meaningful connections within knowing about the individual’s experience within this framework requires the establishment of both a particular culture (e.g., ethnic, ability, or rapport and respect, and Hays suggests several gender-based), and how that should or should not noteworthy guidelines in support of these dynam- inform the process of rapport building. For exam- ics. For example, she recommends that clinicians ple, even if an individual has been raised follow- be aware of the central role respect plays in many ing the dictates of a particular culture, the cultures (e.g., Japanese, Latinx) and, as such, individual may not identify with all aspects of should ask a client the title with which they prefer that culture. To provide a more concrete example, to be addressed. She further notes that self- the author of this section, Jo, was raised in a disclosure can be used to help clients assess the 80 J. Qinaʻau and A. Masuda clinician’s ability to help them (e.g., admitting psychologists to both be aware of and take action ignorance about a particular culturally related based upon ten guiding principles: phenomenon the client is describing). Finally, Hays calls out the nuanced role of nonverbal com- 1. Identity is fluid, intersectional, and shaped munication, as it can have very different meanings by the multiplicity of social contexts; across cultures (e.g., eye contact, silence). 2. Psychologists have limiting assumptions and Hays (2008) stresses that the ADDRESSING biases and should work to acknowledge and acronym should be used to attune to within-group move beyond them; differences, even when a clinician is knowledge- 3. Language and communication are unique to able about the culture of the client. Critical think- individuals and important to consider in ing skills are invaluable in discerning both verbal interactions; and nonverbal communication dynamics, always 4. Social and physical environments are impor- keeping in mind one’s own assumptions. Hard tant aspects of life; and fast rules will always involve potentially 5. Power, privilege, and oppression should be harmful assumptions, making the awareness, considered and equitable mental health engagement, and decision-making skills of the access pursued; therapist key. 6. Interventions should be culturally adapted; The second major framework of cultural con- 7. Globalization has an impact on the psycholo- sideration comes from the multicultural counsel- gist’s self-definition, purpose, role, and ing field, as systematized by Sue and Sue. function; According to Sue and Sue, cultural competence 8. Taking a lifespan perspective, psychologists comprises of three major elements: awareness, must consider how developmental stages knowledge, and skills (Sue & Sue, 2016). intersect with biosocial cultural contexts to Clinician self-awareness of values, beliefs, inform identity and worldview; biases, and patterned reactions provide a strong 9. Strive to conduct culturally appropriate and foundation for relating to clients and building informed practices; rapport. Expanding one’s understanding of other 10. Take a strengths-based approach, build resil- cultures through research and experience, as well ience, and attenuate the negative effects of as exploring adaptations of interventions for cer- trauma. tain cultures in the literature, therapists can build upon the second dimension of multicultural com- These ten recommendations are presented petency (i.e., knowledge). Finally, counselors within an ecological framework of five nested should build specific skills needed to work with levels from the bidirectional model of self- diverse clientele. Sue and Sue suggest that rap- definition and relationships to community, port “sets the stage on which other essential con- school, and family context. Level 3 is the insti- ditions can become effective” (Sue & Sue, 2016, tutional level, which is nested in level 4, inter- p. 159). From their view, building rapport through national climate. Outcomes of treatment define verbal (e.g., communication style) and nonverbal level 5. To improve rapport, the therapist actions (e.g., body language) serves to create an should recognize barriers clients face in their environment of understanding. Such an environ- journey toward wellbeing, especially those ment entails trust, positive emotional climate, related to legal status, stigma, gender identity, credibility, and sharing of worldviews, aspects of and unfamiliarity with research or healthcare the therapeutic relationship that lead to optimal systems. The framework and recommendations results in counseling. presented by the APA have the powerful poten- Finally, in the Multicultural Guidelines: An tial to raise awareness about issues that can Ecological Approach to Context, Identity, and directly impact rapport between the therapist Intersectionality (APA, 2017), the APA urges and client. 7 Functional and Contextaul Account of Common Factors 81

The Case for a Comprehensive to evaluate our therapeutic work through the and Complete System interrelated lenses of cultural considerations and clinical competency. From the perspective of CBS (Hayes, Barnes- From the perspective of CBS, a guiding psy- Holmes, et al., 2012; Hayes, Long, et al., 2013), chological principle, such as the one mentioned which will be described in detail below, there is above, should be greater in both precision and no doubt that extant frameworks of cultural con- scope (Hayes, Barnes-Holmes, et al., 2012; siderations have addressed extremely important Hayes, Long, et al., 2013). Most frameworks of issues related to rapport building and effective cultural considerations tend to focus on a specific therapeutic work. However, CBS also argues group (e.g., culturally humble work for Asian that, if it is our responsibility as behavioral health American behavioral health) or topic (e.g., health professionals to understand rapport and promote disparities in mental health), and yet overlook therapeutic work across a wide array of sociocul- other understudied groups (e.g., Black Americans, turally diverse cases, we need a more comprehen- Latino/a Americans, multiracial, or LGBTQ cli- sive and coherent model, one that includes a ents in the USA) or issues that are equally impor- pragmatic theory of behavioral health (e.g., one tant to be targeted. Said in another way, these that defines greater behavioral health and well- models are only greater in precision for particular ness) and of behavior change (Masuda, 2014a, groups of clients or topics, but may not be greater 2016). However, as argued elsewhere, recent cul- in scope as their applicability is specific to these tural competence and humility efforts are said to particular groups. be too commonly driven by ideology without Finally, as implied above, extant frameworks considering the pros and cons of such culturally of cultural considerations are largely descriptive, focused practices (Lilienfeld, 2017; O’Donohue and they are not built based on the broadly appli- & Benuto, 2010), or without evidence-based psy- cable evidence-based psychological principles chological principles as guides for a culturally of change (Masuda, 2016). That is, these frame- competent and culturally humble practice works are extremely effective in raising our (Masuda, 2016). This is a vitally important con- awareness of the topic of interest and perhaps to cern as well-intentioned efforts could yield coun- promote changes in their very specified domains. terintuitive results, such as the delivery of a more However, when the aim of the cultural consider- culturally stereotypical and insensitive treatment, ations is change, especially one that is outside promotion of implicit biases toward a client, or their scope, descriptive theory may not be so rapport that is indifferent to the client’s behav- effective in pointing out how to bring about ioral functioning and wellbeing (Masuda, 2014a; change. Once again, if the aim of cultural con- Plaut, Thomas, Hurd, & Romano, 2018; Twohig, siderations is the actual change in behavioral, Domenech Rodriguez, & Enno, 2014). social, and interpersonal phenomena across What needs to be done, at least from a CBS diverse sociocultural cases without disparities, it perspective, is to clarify or build psychological is important for us to follow a particular way of principles that inform the link between cultural understanding (i.e., basic unit of analysis), with considerations and behavioral health and treat- particular goals of such understanding (i.e., ana- ment outcome in greater detail. More specifi- lytic goals), and a particular criterion set to eval- cally, such principles should help us see (a) the uate our efforts of such understanding in purpose of cultural considerations, (b) what achieving our goals (i.e., truth criteria). We makes given cultural factors important to be con- believe that a perspective of contextual behav- sidered in the context of behavioral health and ioral science (CBS) and its underlying philoso- psychotherapy, (c) ways to identify which cul- phy, theories, and practices are particularly tural factors are important to consider even when useful to pursue this aim (Hayes, Long, et al., they are not explicitly shared in a case, (d) ways 2013; Masuda, 2014a, 2014b). Below is a brief to promote cultural considerations, and (e) ways overview of CBS. 82 J. Qinaʻau and A. Masuda

Contextual Behavioral Science opment of multiple levels of a research program as an Overarching Framework including philosophical assumption, basic sci- of Synthesis ence, basic and applied theory, intervention development, and treatment testing” (Hayes, Common factors and cultural considerations are Levin, et al., 2013). Further, CBS is “a wing of both major topics in the complex process of treat- science that explicitly embraces pro-sociality and ment development. To date, there is no well- human development as a goal of scientific and articulated and agreed upon model of treatment professional development” rejecting all other development in the field of behavioral health. models which seek to minimize aspects of the The lack of a coherent model has obstructed human experience in order to fit a given theory progress in a number of important ways. Hayes, (Hayes, Barnes-Holmes, et al., 2012). Long, et al. (2013) stated that: Outside forces such as research funding requirement, changes in psychiatric nosology, or agency Functional Contextualism regulations regarding evidence-based treatments, as the Worldview of Contextual seem to have as much or more influence on meth- Behavioral Science ods of treatment development than do strategic visions of clinical researchers. As a result, psychological treatment development is a patchwork of Every researcher, clinician, and theorist in the strategies, many ad hoc, conducted in diverse field of behavioral health follows a particular research traditions. The field needs to consider philosophical worldview or two, often without how the various methods at its disposal can be integrated into a long-term strategy to create real prog- knowing it (Hayes, Hayes, & Reese, 1988). For ress (p. 871). those of us who are involved in the field of behavioral health, it is important to explicate and take Hayes and colleagues (Hayes & Hofmann, 2018; responsibility for our own underlying worldview Hayes, Levin, Plumb-Vilardaga, Villatte, & (e.g., philosophy of science, a general perspec- Pistorello, 2013; Hayes, Long, et al., 2013) then tive, a set of underlying assumptions). This is proposed a contextual behavioral science (CBS) because one’s worldview serves as a foundation approach as one possible way to rise to this chal- where our theories, data, interpretation of data, lenge. They defined CBS as follows: and applications (e.g., treatment intervention, Grounded in contextualistic philosophical therapeutic relationship, cultural adaptation) are assumptions, and nested within multidimensional, accumulated and refined over time (Herbert, multi-level evolution science as a contextual view Gaudiano, & Forman, 2013; Hughes, 2018; of life, it seeks the development of basic and Klepac et al., 2012). Without a clear and coherent applied scientific concepts and methods that are useful in predicting-and-influencing the contextu- foundation, we run the risk of models and prac- ally embedded actions of whole organisms, indi- tices built upon it being disorganized and vidually and in groups, with precision, scope, and contradictory. depth; and extends that approach into knowledge As described above, clarification of one’s own development itself so as to create a behavioral science mode adequate to the challenges of the philosophical worldview promotes the develop- human condition (Hayes, Barnes-Holmes, et al., ment and refinement of clinical knowledge (e.g., 2012, p. 2). theories) and technology in a coherent fashion (Herbert et al., 2013; Klepac et al., 2012). Said in a more applied way, CBS is summarized Particularly relevant to the topic of the present as “a principle-focused, inductive strategy of psy- chapter, the clarification of one’s worldview is also chological system building, which emphasizes crucial for integrating, assimilating, and synthesiz- developing interventions based on theoretical ing a vast array of theories and practices from models tightly linked to basic principles that are diverse schools (e.g., common factors, cultural themselves constantly upgraded and evaluated. It considerations, clinical effectiveness) into: (a) a involves the integration and simultaneous devel- philosophically coherent framework of analysis 7 Functional and Contextaul Account of Common Factors 83

(e.g., what the subject of interest is and how it is whether Aki, an author of this chapter, is compe- understood); with (b) principal goal of analysis tently incorporating common factors and cultural (e.g., description, prediction, influence, and predic- humility into his practice). For a functional con- tion-and-influence); and (c) truth criteria to be fol- textualist, it is critical to understand which lowed to evaluate one’s own work (e.g., behaviors of Aki may reflect the concepts of com- correspondence, successful working) (Hayes et al., mon factors or cultural humility, which contex- 1988; Masuda & Rivzvi, 2019). In other words, a tual factors currently maintain these behavioral given philosophical worldview gives us the frame- tendencies, and which contextual factors one can work of understanding with a given stated goal as systematically arrange to influence and promote well as the way to evaluate the progress of our his behaviors of cultural humility in the future. work. Below is the brief overview of functional Said in another way, functional contextualism contextualism, the underlying worldview of CBS. emphasizes the importance of context (e.g., Regarding the fundamental unit of analysis, learning history and current circumstance) that functional contextualism views the phenomenon can be systematically arranged by the person. It of interest in terms of the “act of a whole person is only the context that the client and practitioner in context” (i.e., behavior–environment interac- can systematically add and arrange for promoting tions as a whole) (Hayes, Barnes-Holmes, et al., and nurturing their effective therapeutic work 2012; Klepac et al., 2012). This means that, from (Hayes, 2005a; Hayes & Toarmino, 1995). a CBS perspective, any behavioral phenomenon Furthermore, functional contextualism of interest, such as cultural competency, treat- requires its analytic goal of prediction-and- ment rapport, and common factors in psychother- influence to be greater in precision and scope apy, is assimilated into the framework of an act of (Hayes, Barnes-Holmes, et al., 2012; Hayes, a whole person (e.g., client, therapist) that is Levin, et al., 2013). That is, theories and prac- manifested as the intersection of one’s learning tices derived from the standpoint of functional history and current circumstance. It is also impor- contextualism must be useful in accurately tant to note that this functional unit of analysis predicting-and-influencing the target behavioral can be set flexibly based on the analysis of inter- phenomena of interest (e.g., cultural humility) est, ranging from a single strand of a stable not only in a given specific circumstance (e.g., behavioral pattern (e.g., negative affect) of a per- Aki working with a given client), but also in son in a given therapeutic moment to a whole many other circumstances (e.g., Jo and other cli- behavioral repertoire of an individual throughout nicians working with diverse clients in diverse course of intervention and follow-ups (Hayes, sociocultural contexts). Barnes-Holmes, et al., 2012). Finally, unlike other worldviews, functional Regardless of the size of this functional unit, contextualism de-emphasizes ontology in truth the primary goal of functional contextualism is criterion, and assumes that theory, practice, and the prediction-and-influence of the behavior of knowledge are constructed and justified for a pre- interest (Hayes, Barnes-Holmes, et al., 2012). analytically stated purpose and aim, rather than “Prediction-and-influence” here is a unified goal: discovered. In other words, what is true for func- analyses should help accomplish both simultane- tional contextualism is what is working (Biglan ously. More specifically, theories and practices & Hayes, 1996). that are based on functional contextualism tend to insist on a stronger version of determinism as reflected in the emphasis on a principle-informed Psychological Flexibility as a Model idiographic approach (Hayes, Long, et al., 2013; of Behavioral Health Klepac et al., 2012). For this reason, for a functional contextualist, it is not enough for a theo- In CBS, the Psychological Flexibility Model retical framework to be descriptive (e.g., what (PFM) serves as an applied model of behavioral common factors and cultural humility are or health and behavior change (Hayes, Barnes- 84 J. Qinaʻau and A. Masuda

Holmes, et al., 2012; Hayes, Long, et al., 2013). logical issues to be resolved further (Hayes et al., A larger body of evidence now suggests that the 1996; Hayes et al., 2011). PFM and acceptance and commitment therapy Furthermore, the PFM proposes three sets of (ACT), a PFM-informed psychosocial interven- behavior repertoires that collectively promote tion, are useful in understanding, predicting, and greater behavioral health and psychological flex- influencing behavioral phenomena of interest in ibility. In CBS, these three repertoires are called diverse sociocultural contexts (Atkins et al., centered, open, and engaged response styles. The 2017; Kashdan & Rottenberg, 2010). Empirical centered response style is a group of contextually investigation directly exploring cultural compe- situated behavioral processes, including the skills tence in ACT is promising, though still in its of (a) intentionally becoming aware of whatever nascent phase (see Woidneck, Pratt, Gundy, one is experiencing moment-by-moment; (b) Nelson, & Twohig, 2012). Additionally, PFM- shifting, focusing, and expanding one’s inten- informed theoretical accounts of the therapeutic tional awareness and focus; and (c) experiencing relationship and cultural considerations are avail- the self as the context where all perceptual expe- able elsewhere (Hayes et al., 2011; Hayes, riences unfolds (Masuda & Rivzvi, 2019). In Strosahl, et al., 2012; 2014b; Masuda, in press). practice, such terms as present moment aware- According to the PFM, most behaviors (i.e., ness, self-as-context, and being mode of mind are anything one does and says) in normally devel- used to describe and teach this skillset. For PFM- oped adolescents and adults are cognitively and informed psychosocial interventions (see Hayes socially regulated and maintained. In other et al., 2011), this centered awareness or sense of words, the context of normally developed self serves a behavioral prerequisite for establish- humans (e.g., clients, clinicians) is verbal, inter- ing effective open and engaged response styles as personal, and sociocultural. Similarly, many pre- well as for forming and sustaining an effective senting concerns brought by clients are cognitive therapeutic relationship (Hayes, Strosahl, et al., and interpersonal, and our efforts to resolve 2012). these concerns are also cognitively and cultur- The open response style points to a particular ally regulated (Hayes et al., 2011; Hayes, Wilson, functional quality of responding to the present Gifford, Follette, & Strosahl, 1996). A major moment experience in a given context. It refers to implication of this model is that the problems of the extent to which one is experiencing whatever cognitions and other private events (e.g., sensa- one is experiencing in the present moment fully tions, feelings, perceptions) are not so much and openly as it is without reacting to them or their occurrence or content, but the way a person acting on them (Hayes et al., 2006; Hayes et al., has learned to respond to them (Anderson, 2011). In contemporary CBTs and other psycho- Hawkins, & Scotti, 1997; Hayes & Brownstein, therapies, the terms acceptance, metacognitive 1986; Hayes & Wilson, 1995; Wilson, Hayes, & awareness, mentalization, decentering, defusion Gifford, 1997). (i.e., looking at a thought as a mental event), and The PFM also argues the paradox of cogni- the like, often are used to capture the aspects of tively regulated behavior as being at the core of this behavioral process. human psychopathology. That is, otherwise use- Finally, according to the PFM, what makes ful and economical, cognitive process can also life truly meaningful is engaging in everyday give rise to problems unique to humans by mak- activities directed by self-constructed values. ing individuals insensitive to the here-and-now Values in this context can be understood as experience (Hayes, Strosahl, et al., 2012). More freely chosen, verbally constructed conse- specifically, this insensitivity due to human cog- quences of ongoing, dynamic, and evolving pat- nitive process (e.g., attachment to the literality of terns of activities (Wilson & Dufrene, 2008). In cognition, experiencing it as if it were a “true practice, for example, dedication and honesty thing”) perpetuates futile problem-solving and are chosen values for many adult clients; these avoidance efforts that can exacerbate the psycho- personally chosen values can serve as a behav- 7 Functional and Contextaul Account of Common Factors 85 ioral compass, and makes any activities that A detailed description of how the PFM serves reflect them (e.g., working through a challeng- as a model of behavior change as well as practical ing project without giving up) intrinsically methods derived from the PFM requires an entire meaningful. Another value example might be volume, and in fact several such volumes are altruism; if a client values altruism, or acts of available elsewhere (e.g., Hayes, 2005b; Hayes, service, but has not actively engaged in such Strosahl, et al., 2012; Luoma, Hayes, & Walser, projects recently, a therapist may encourage 2017). For this reason, this section will simply such engagement. As such, the term engaged present a brief summary of applied guidelines for response style represents a set of behavioral rep- practice derived from the PFM (also see Masuda, ertoires with this functional quality (Hayes 2016, in press). These are: et al., 2011). In sum, greater behavioral health or psycho- (a) Many of clients’ presenting concerns (e.g., logical flexibility is characterized by the combi- problematic behaviors, negative affect, loss nation of centered, open, and engaged response of purpose, apathy, negative self-appraisal, styles, and in CBS, this unified model serves as a relationship conflicts) are cognitively generalized theory of behavioral health and well- enmeshed and regulated, and their efforts to being (Hayes, Long, et al., 2013; Kashdan & solve these concerns are also cognitively Rottenberg, 2010). These behavioral skills do not regulated. necessarily erase psychological struggles, but (b) These cognitively regulated phenomena are help individuals to navigate through the joy and learned, and socioculturally shaped and sorrow of their lives. In a review of the PFM, maintained. Hayes et al. (2011) summarize the unification of (c) A case conceptualization is formulated in centered, open, and engaged response styles as terms of act-in-context: That is, the extent to follows: which clients engage in unworkable and Like the legs of a stool, when a person is open, automatic behavioral and cognitive efforts aware, and active, a steady foundation is created to downregulate unwanted private events for more flexible thinking, feeling, and behaving. (e.g., experiential avoidance), the deficits in Metaphorically, it is as if there is greater life space activities that are meaningful or fulfilling in which the person can experiment and grow and can be moved by experiences. Although not all of (e.g., lack of committed action) for clients, the approaches target all of the processes, it seems and factors that maintain these behavioral as though contextual forms of CBT are designed to patterns. increase the psychological flexibility of the partici- (d) The case conceptualization should inform pants by fostering a more open, aware, and active approach to living (p. 160). the client’s current levels of psychological flexibility as well as the targeted level of psychological flexibility (e.g., treatment goals) using the behavioral dimensions of Psychological Flexibility as a Model centered, open, and engaged response styles. of Behavior Change The case conceptualization also should inform a treatment plan by the behavioral From a CBS perspective, the goal of psychother- chain-analysis of how to work with the cli- apy and other forms of behavioral health practice ent step-by-step toward the end goal. is the promotion of behavioral health and psycho- (e) It is important to identify contextual factors logical flexibility. As such, common factors, such that can be systematically manipulated by as rapport, as well as cultural considerations, are client, clinician, or both to promote cen- understood using the framework of PFM and tered, open, and engaged response styles. how to promote behavioral health and psycho- (f) The promotion of centered, open, and logical flexibility. engaged response styles is done by adding a new learning history and experience to the 86 J. Qinaʻau and A. Masuda

client’s extant repertoires (i.e., adding a new also translated into the act-in-context both from contextual experience to one’s extant “act- the perspective of client and that of therapist. In in-historical and situational context”). other words, cultural phenomena and common (g) The addition of new learning should be bot- factors are important insofar as they relate to the tom-up (e.g., experiential) more so than top- client’s therapeutic goals. down (e.g., “didactic”). Take, as an example, Soha, a 23-year-old (h) Clients’ sociocultural factors (e.g., upbring- woman who identifies as queer and Muslim and ing, learning history, verbal antecedent and has a therapeutic goal of improving her relation- consequence, verbal community) are func- ship with her mother as the stress from this dyad tionally understood by translating them into exacerbates feelings of despondence and nega- the target behavioral processes of change tive self-referential thinking. If Soha’s mother is identified in (c). fully accepting of her daughter’s sexual orienta- (i) From the perspective of a therapist, psycho- tion, it is perhaps unnecessary to factor this cul- therapy should be translated into “the act of tural consideration into the analysis. However, if therapist-in-context,” Soha’s queerness is a point of contention between (j) For the same reason, common factors and the two, analysis of this factor is functionally rel- specific therapeutic ingredients should be evant to the therapeutic endeavor, and should translated into “the act of therapist- therefore be considered by the clinician and dis- in-context.” cussed with the client. If Soha’s mother refer- (k) Therapeutic work and therapeutic relation- ences Islamic values in her disapproval of Soha’s ship should be evaluated based on their queerness, then the therapist should incorporate effects on the intended outcomes in both cultural considerations of religion and spirituality immediate and long-term. into the work. However, if Soha’s mother disap- (l) Context in “the act of therapist-in-context” proves of Soha’s queerness because it may inter- refers to the therapist learning history and fere with Soha’s likelihood of having children, the current and ongoing interaction with a their Muslim orientation is not necessarily as rel- client in therapy. evant to the stated therapeutic goal. Clearly, a (m) The promotion of greater behavioral health topographical, content-focused account of cul- and psychological flexibility does not neces- ture is not recommended from a CBS perspec- sarily require the elimination of presenting tive. What is key here is the process of discerning concerns in form or frequency. the functionality and contextuality of cultural (n) Change in how one relates or responds to information as it relates to therapeutic success. problematic internal events (e.g., psycho- For a more thorough examination of this process, logical openness) along with the promotion please refer to Masuda (2014b). of intrinsically reinforcing and adaptive behaviors (e.g., committed action) is sufficient to promote greater behavioral health Contextually and Pragmatically and psychological flexibility. Situated Acts of the Clinician

A major takeaway from these guidelines, with In CBS and PFM, a therapeutic relationship is regard to the aim of this chapter, can be found in viewed as the contextually situated, ongoing, principles (h) and (j): a client’s sociocultural fac- and dynamic interplay between the client and the tors are functionally understood by translating therapist as historical and situational beings them into the target behavioral processes of (Hayes, Strosahl, et al., 2012, see pp. 141–149). change identified in the case conceptualization, In this account, psychotherapy and therapeutic as formulated in terms of the act-in-context. relationship can be understood from the perspec- Similarly, as described in detail below, therapeu- tive of a therapist as well as that of a client. From tic common factors and specific ingredients are the perspective of the therapist, psychotherapy is 7 Functional and Contextaul Account of Common Factors 87 a contextually situated, purposeful act of a clini- Psychological Flexibility cian in a therapeutic context that is principle- as Culturally Situated Behavioral informed and experientially guided (Masuda, Repertoires 2014a, 2016). More specifically, psychotherapy is said to be purposeful in that the clinician’s The promotion of behavioral health and flexibil- actions are intentionally directed toward a cli- ity, characterized by centered, open, and engaged ent’s greater behavioral health (e.g., interper- living is the overarching treatment goal and sonal connection, purposeful living, direction of psychotherapies that are informed by psychological flexibility) regardless of how it is the PFM (Hayes et al., 2011). In CBS, this func- manifested topographically. From the CBS per- tional framework of psychological flexibility is spective, psychotherapy is principle-informed, theorized to be universally applicable, although as the clinician’s behavior is always guided, its topographical manifestations can vary signifi- whether implicitly or explicitly, by the theoreti- cantly across individuals (Masuda, 2014a, 2016, cal model of behavior change and wellness (i.e., in press). The latter is the case because different the PFM of behavior health and behavior sociocultural contingencies operate in these indi- change). From its inception (see Hayes, Barnes- viduals’ sociocultural contexts. For example, for Holmes, et al., 2012; Hayes, Long, et al., 2013), some, an individualistic worldview (e.g., indi- the proponents of PFM have made great efforts viduality, personal achievement, and autonomy) to improve and refine the PFM as a guide for continues to be the driving force that shapes psy- case formulation, treatment planning, and actual chologically flexible behavioral patterns (Markus treatment that are applicable to diverse clinical & Kitayama, 1991; Weisz, Rothbaum, & cases (Hayes, Pistorello, & Levin, 2012; Hayes, Blackburn, 1984). For others, a collective and Strosahl, et al., 2012). For clinicians, the thera- interdependent worldview (e.g., harmony and peutic relationship is also an interpersonal con- conformity to the collective whole) may serve as text that requires them to be experiential and an underlying principle of engaged and meaning- flexible in response to ongoing changes in each ful living (Markus & Kitayama, 2010). therapeutic moment with the client (Kohlenberg These differential social contingencies may & Tsai, 2007). shape psychologically flexible behaviors of indi- For clients, the therapeutic relationship is a viduals differently across key life domains, such context where they can learn a new set of behav- as family relations, parenting, peer socialization, iors, insights, and personal growth (e.g., behav- and intimacy (Hayes & Toarmino, 1995; Masuda, ioral health and psychological flexibility) in press). For example, the direct expression of through interacting with a clinician (Robins, one’s thoughts and opinions (e.g., assertiveness) Schmidt, & Linehan, 2004). For them, it is also a tends to be valued in many Western sociocultural context where the therapist serves as a crucial contexts, and it is often viewed as part of a psy- contextual factor for the client’s behavior chologically flexible behavioral pattern. However, change. Particularly relevant to the topic of this being assertive in this behavioral form may not chapter, the building of rapport requires the cli- be a culturally supported practice for individuals ent and clinician to be psychologically flexible in other sociocultural contexts. For example, Aki (i.e., centered, open, and engaged response grew up in a collective rural culture in Japan. styles) in any given moment and responsive to When in Japan, he refrained from expressing his the context of the relationship and specific stated thoughts openly to peers and authority figures as goals. A psychologically flexible therapist he was taught that expressing what he wants embodies the core concepts of open, aware, and leads to the disruption of interpersonal harmony engaged living (Hayes, Strosahl, et al., 2012). and is a sign of personal weakness. As such, he Doing so then creates a context in which the cli- developed a set of communication skills that ent can develop their own mastery of these orien- appear too passive for Westerners, and yet func- tations and skills. tionally effective in his sociocultural context. As 88 J. Qinaʻau and A. Masuda such, the manifestations of greater behavioral vertical, prescriptive, and directive that are often health may look different for different clients, on considered less than ideal therapeutic relation- the behavioral surface. It is the underlying pro- ship styles, may be optimally effective for other cess—utilizing the psychological flexibility clients (Allen, Cox, et al., 2016; Allen, Kim, framework in achieving health and wellbeing— Smith, & Hafoka, 2016). that is the key. As presented elsewhere (Masuda, in press), In sum, what is crucial for clinicians is to when the author Aki works with Asian American judge whether a given behavior of a client is and Native Hawaiian clients in Hawai’i who are linked to psychological flexibility for that client younger than him, he tends to present himself as in a given sociocultural context by looking at its an authority figure, initially, in order to build functional and adaptive qualities (e.g., centered, their perceived confidence in Aki as their clini- open, and engaged living). This is a primary cian. He also tends to be more directive than he requirement of cultural considerations from the might be in sessions held in the mainland CBS lens. In practice, a culturally and individu- USA. This is, in part, because Polynesian cul- ally sensitive understanding of psychological tures often value the wisdom of age and respect flexibility can start with asking the client ques- for elders (Capstick, Norris, Sopoaga, & Tobata, tions such as, “If this presenting concern is no 2009; Mesiona Lee & Look, 2017; Mokuau, longer an issue, what do you hope to do more of 1990), and behaving in this way tends to be con- in your life?” and “If you are doing that, I was gruent with cultural expectations. Similarly, wondering if you feel alive, as opposed to feeling when he works with Asian American and Native small or constrained.” By asking about the cli- Hawaiian clients, and even some White ent’s hopes for the future, values, culturally Americans in Hawai’i who are older than him, he informed and otherwise, will implicitly come to tends to present himself as polite and humble to the fore. Questions need not be about culture, indirectly express his respect for them. As such, explicitly. Aki’s therapeutic relationship with clients in Hawai’i is not necessarily horizontal or nondirective, as is often suggested by person-focused Rapport Building, Therapeutic and experiential psychotherapies, such as ACT. Relationship, and Stance However, this form of therapeutic relationship is of the Therapist still PFM- or common factors theory-consistent (Hayes et al., 2011; Norcross & Lambert, 2018; As seen in many PFM-informed psychosocial Wampold & Imel, 2015) if it functions to pro- treatments, an effective therapeutic relationship mote greater behavioral health and psychological is often expected to be intense and experiential flexibility. The take-home message here is that with a strong interpersonal and emotional con- effective styles of therapeutic relationships can nection between client and therapist (Hayes, vary greatly across different client-therapist Strosahl, et al., 2012, pp. 141–142). However, dyads in form, and it is crucial for the therapist to from a CBS perspective, it is important to note have the ability to fine-tune their relationship in that this form of interpersonal style (e.g., the ther- each moment accordingly, in service of the pro- apist being warm, expressing empathy, validat- motion of psychological flexibility (Koerner, ing, etc.) will not necessarily be effective for all 2012; Sue, Zane, Hall, & Berger, 2009). clients. Similarly, genuineness, empathy, positive Relatedly, a therapist’s self-disclosure in ses- regard, and cultural adaptation may take different sion is often discussed in cultural consideration forms across clients to be effective. Once again, and common factors literature, and is a central whether a given therapeutic bond is optimal is topic in PFM-informed therapist training (Hayes, determined by the extent to which it promotes the Strosahl, et al., 2012). Self-disclosure can be client’s behavioral health and psychological flex- extremely helpful in building rapport, but should ibility. In fact, a therapeutic interaction that is only be utilized if it is therapeutic for the client 7 Functional and Contextaul Account of Common Factors 89

(Masuda, in press)—the therapist’s self-ages the client and clinician to be centered, open, disclosure may not always be therapeutic for all and engaged in their therapeutic relationship to clients, at least initially. Self-disclosure could be pursue greater psychological flexibility. in direct service of the client’s goals (e.g., if they Important cultural considerations and key com- are trying to build interpersonal skills like empa- mon factors can therefore be understood through thy or understanding), or it could be indirect the lens of centered, open, and engaged response (e.g., the therapist could be modeling how the cli- styles that unfold in the unique therapeutic rela- ent may openly share their past experiences). For tionship at hand. While the dodo bird may cer- some clients, self-disclosure is not part of their tainly have been on to something quite sociocultural norm, at least not during the initial groundbreaking, CBS provides a lens through phase of interpersonal relationship, and the thera- which only the most meaningful strides are pur- pist’s self-disclosure may evoke unintended reac- sued in the race toward greater wellbeing. tions from clients (e.g., extreme discomfort, losing confidence in the therapist). For this reason, it is important for clinicians to be mindful of References the timing and content of self-disclosure. For example, Aki will not self-disclose any of his Ahn, H.-n., & Wampold, B. E. (2001). Where oh where own previous struggles unless they have estab- are the specific ingredients? A meta-analysis of component studies in counseling and psychotherapy. lished a safe therapeutic context where experien- Journal of Counseling Psychology, 48(3), 251–257. tial learning, including self-disclosure, is Allen, G. E. K., Cox, J., Smith, T. B., Hafoka, O., Griner, validated and encouraged. D., & Beecher, M. (2016). Psychotherapy utilization and presenting concerns among Polynesian American college students. The Counseling Psychologist, 44(1), 28–49. Summary and Conclusions Allen, G. E. K., Kim, B. S. K., Smith, T. B., & Hafoka, O. (2016). Counseling attitudes and stigma among In conclusion, contextual behavioral science Polynesian Americans. The Counseling Psychologist, 44(1), 6–27. (CBS) provides a framework, within which cli- American Psychological Association. (2017). ents’ unique sociocultural factors (e.g., upbring- Multicultural guidelines: An ecological approach ing, learning history, one’s sociocultural to context, identity, and intersectionality. Retrieved environment) as well as therapeutic common fac- from: http://www.apa.org/about/policy/multicultural- guidelines.pdf tors can be functionally and contextually under- Anderson, C. M., Hawkins, R. P., & Scotti, J. R. (1997). stood. In terms of functionality, to what extent Private events in behavior analysis: Conceptual basis are these factors related to the unique therapeutic and clinical relevance. Behavior Therapy, 28(1), goals of this unique client? In terms of context, 157–179. Atkins, P. W., Ciarrochi, J., Gaudiano, B. A., Bricker, how might these factors reshape the contexts of J. B., Donald, J., Rovner, G., … Hayes, S. C. (2017). the therapist, the client, and the therapist–client Departing from the essential features of a high qual- interaction? More specifically, to keep the prag- ity systematic review of psychotherapy: A response to matic aim of prediction-and-influence with preci- Öst (2014) and recommendations for improvement. Behaviour Research and Therapy, 97, 259–272. sion and scope in mind, these cultural and Bernal, G., & Scharró-del-Río, M. R. (2001). Are empiri- therapeutic common factors are translated into cally supported treatments valid for ethnic minorities? the “act-in-context” of the treatment target. In our Toward an alternative approach for treatment research. view, the CBS approach provides guiding theo- Cultural Diversity and Ethnic Minority Psychology, 7(4), 328–342. ries of behavioral health and behavior change to Biglan, A., & Hayes, S. C. (1996). Should the behavioral better understand cultural considerations and sciences become more pragmatic? The case for func- therapeutic common factors that are relevant to tional contextualism in research on human behavior. treatment and to bring about actual change in Applied & Preventive Psychology, 5(1), 47–57. Black, J. D. (1952). Common factors of the patient- behavioral health and wellbeing via the psycho- therapist relationship in diverse psychotherapies. logical flexibility model. The CBS model encour- Journal of Clinical Psychology, 8(3), 302–306. 90 J. Qinaʻau and A. Masuda

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Silvia Alves Nishioka, Cindy Y. Huang, and Nolan Zane

Disparities in health can be defined as the dis- extensive literature review including over 600 crepancy between the mental health needs of a articles on health disparities and observed that certain group compared to the treatment received there was no significant change in access to men- (McGuire, Alegria, Cook, Wells, & Zaslavsky, tal health care among minority groups compared 2006). Mental health disparities continue to be a to White. The authors observed that factors such pressing problem among minority communities as negative attitudes towards mental health, (Cook et al., 2018; Sue, Fujino, Hu, Takeuchi, & immigrant status, and economic strains were Zane, 1991). In a large study, Sue et al. (1991) consistently associated with disparities. Clearly, examined the utilization rates of the mental mental health disparities continue to be a perva- health system for a five-year period. The authors sive issue that significantly affects minority observed that African Americans had higher uti- communities. lization rates (20.5%) given their representation Another recent study highlighted the differ- in the area (12.8% of the total population) com- ences in access and diagnosis rates among African pared to Asian Americans and Latinos utilization American, Latino, and White clients of a large pub- rates (3.1% and 25.5%) and their representation lic inpatient service in the Northeast (Delphin- in the area (8.7% and 33.7%). The results Rittmon et al., 2015). Latino individuals were more strongly indicate a pattern of overutilization and, likely to access services through crisis-emergency possibly, over-diagnosing certain minority referrals, whereas African American clients were groups, while others have a significant underuti- more likely to be referred to services by other inpa- lization. Either patterns may not be adequately tient units. Moreover, African American individu- addressing minority groups mental health needs. als were more likely to receive diagnoses such as More recently, Cook et al. (2018) conducted an schizophrenia, mood disorder, or substance use. On the other hand, Latino clients were more likely to be discharged from the inpatient unit without a S. A. Nishioka (*) · C. Y. Huang conclusive diagnosis (Delphin-Rittmon et al., Department of Counseling and Clinical Psychology, 2015). These findings suggest that racial and ethnic Teachers College, Columbia University, New York, NY, USA minority groups may experience systematic biases e-mail: [email protected]; in treatment which may not account for the cultur- [email protected] ally specific presentations, values, and beliefs N. Zane around mental health issues. Being multiculturally Department of Psychology, University of California, competent involves understanding what specific Davis, Davis, CA, USA factors affect minority clients and their access to, e-mail: [email protected]

© Springer Nature Switzerland AG 2020 93 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_8 94 S. A. Nishioka et al. engagement in, and benefits from mental health characteristics, preferences, and circumstances; treatments. To address mental health disparities, it and clinical expertise. The metaphor attempts to is crucial to further develop culturally sensitive encapsulate the interdependency of research, interventions and test their effectiveness in decreas- clients, and clinical practice as each one informs ing mental health problems. and is informed by the other. Although mental health disparities are perva- Although ESTs have demonstrated positive sive and affect most ethnic minority communi- effects in treating a variety of mental health prob- ties, this review primarily focuses on research lems, methodological issues limit the generaliz- involving African American, Asian American, ability of the results for minority communities. and Latino clients. The dearth of efficacy studies Recently, Spielmans and Flückiger (2018) with Native American, Native Alaskan, and reviewed 15 meta-analyses on psychotherapy Pacific Islander participants is a significant limi- process aiming to investigate potential modera- tation in the literature. This chapter presents and tors. The authors examined different study vari- discusses the research on empirically supported ables that could influence treatment outcomes treatments for ethnic minorities and the cultural such as clients’ preferences regarding different considerations that may impact their effective- treatment modalities, therapist effects, character- ness. In addition, the proximal-distal model is istics on treatment, and sample representative- presented to provide one framework of how cul- ness that directly affects the generalizability of tural considerations may be incorporated into the findings beyond the study sample. The authors research and empirically supported treatments pointed out that clinical trials and meta-analyses for these clients. Finally, limitations and future should include more detailed information about directions in this field are discussed. the sample characteristics allowing co-researchers and clinicians to contextualize the results (Spielmans & Flückiger, 2018). In other words, it Empirically Supported Treatments should be clear in intervention studies where, to whom, and how interventions have shown evi- Empirically supported treatments (ESTs) are dence of their effectiveness. Yet, many studies do described as interventions with research evi- not sufficiently describe their participants’ char- dence of their efficacy to treat certain conditions acteristics and do not reflect on the impact of (Spring, 2007). Because of their systematic these factors on the results (Spielmans & evaluation and demonstrated results across vari- Flückiger, 2018). ous studies, ESTs are considered best practice Such limitations should be factored in by cli- for psychological treatment (APA, 2005). ESTs nicians when deciding if and how to implement are one of the components of an evidence-based ESTs. Helms (2015) reviewed three meta- practice, defined as the integration of evidence analyses on evidence-based treatments for minor- gathered through research with clinical exper- ity populations and found that most studies tise as well as clients’ characteristics, values, conceptualize race and ethnicity as sociodemo- and context (Sackett, Straus, Richardson, graphic categories instead of examining them as Rosenberg, & Haynes, 2000). Sackett et al.’ constructs that may affect diagnoses, treatment (2000) definition of evidence-based practice and processes, and outcomes. That is, cultural factors the American Psychological Association policy that underlie the racial and ethnic categories may (2005) underscore that incorporating the client’s have a significant effect on how mental health unique characteristics and context is an essential and mental health treatments are experienced by step in the treatment process to enhance out- minority clients. However, such cultural factors comes. Spring (2007) explains the treatment are not accounted for when studies operationalize decision-making process with the metaphor of a their variables only as sociodemographic catego- “three-legged stool” comprising of the best ries. Considering the unique experiences of available research evidence; clients’ values, minorities, researchers and clinicians have tried 8 Friend or Foe: Empirically Supported Treatments for Culturally Minority Clients 95 to adapt ESTs to make them more culturally rel- intervention (84% of reviewed studies) was by evant for diverse communities. explicitly incorporating cultural values and beliefs of the target group in the intervention, such as using a cultural folk tale in a storytell- Culturally Adapted Evidence- ing intervention with minority children. The Supported Treatments meta-analysis found an overall effect size of d = 0.45 (SE = 0.04, p < 0.0001), indicating a One method to convert ESTs into more “friendly” small to moderate effect of adapted interven- interventions for minority clients is to adapt them tions in promoting positive outcomes. by incorporating specific cultural values, experi- However, there was significant variability in ences, and contextual circumstances into treat- the intervention effect sizes across studies indi- ment. Most studies of adapted interventions cating that certain characteristics were moderat- employ a “top-down” approach where an existing ing the outcomes. Variables such as sample (e.g., treatment is tailored to a specific group (Bernal & ethnicity), methodological procedures (e.g., ran- Rodríguez, 2012). Common aspects that are domization, no group comparison), type of cul- modified in the intervention are the language tural adaptation, and outcome measures (e.g., used to deliver it, the content of the sessions or mental health symptoms, attrition rates) signifi- curriculum, and the inclusion of metaphors and cantly influenced the effectiveness of the inter- examples that are specific to the target group. vention (Griner & Smith, 2006). Particularly, Some researchers have criticized the “top-down” clients who identified as Hispanic/Latino(a) approaches, as they tend to make changes that are (d = 0.56), Asian (d = 0.53), or Native American arbitrary and do not necessarily reflect the com- (d = 0.65), and who were less acculturated to the munity values and circumstances (Hwang, 2006). mainstream American culture (d = 0.50) were Other conceptual models of adaptations include found to benefit more from adapted interventions “bottom-up” approaches, which emphasize the compared to other groups. This finding suggests design of interventions within the cultural con- that the outcomes of adapted interventions are text, being that the intervention is originally cre- not equally distributed among diverse popula- ated for that specific group attending to their tions, which highlights the importance of identi- needs and resources (Bernal & Rodríguez, 2012). fying treatment moderators and mediators that Independently from the conceptual model used, are specific to these groups. the process of adapting an intervention should be The authors also examined the effects of the systematic and based on cultural factors that are ethnic match between client and therapist as well linked to treatment processes and, thus, relevant as the language spoken by the therapist other to improve outcomes. Yet, many adaptations do than English (Griner & Smith, 2006). Ethnic not clearly justify the treatment changes, there- match refers to the pairing of therapists and cli- fore limiting the generalizability of the findings. ents who have the same ethnic background in an In this section, the literature on adapted ESTs for effort to enhance client engagement and the minority groups will be reviewed to highlight intervention’s cultural sensitivity. The results current findings and challenges in the field. showed that when ethnic match was attempted, it Griner and Smith (2006) reviewed 76 studies did not have a significantly higher effect size that tested the effects of adapted interventions compared to when there was no report of ethnic for minority clients. Participants from all stud- match (d = 0.31 versus d = 0.58). This suggests ies (N = 25,225) identified as African Americans that ethnic match alone may not be a significant (31%), Hispanic/Latino(a) Americans (31%), factor to improve minority client engagement Asian Americans (19%), Native Americans and treatment outcomes. On the other hand, it (11%), European Americans (5%), or not speci- was found that when therapy was provided in the fied (i.e., “other”; 3%). The authors observed same language as the client (other than English) that the most common method of adapting the the effect sizes were larger than when there was 96 S. A. Nishioka et al. no report of this characteristic (d = 0.49 versus match between therapist and client was not a sig- d = 21). This finding indicates that language nificant moderator of these effects (B = −0.51, match may be more relevant to minority clients p = 0.52). In contrast to the previous research than the racial/ethnic match in adapted interven- study, the language of the intervention other than tions. Thus, services provided in the client’s pre- English was not found to be a significant modera- ferred language may not only be more accessible tor in this meta-analysis (B = 0.29, p = 0.73). This for minority clients but may also increase the result may be related to the large number of inter- treatment effectiveness (Griner & Smith, 2006). national studies included in the analyses indicat- A more recent meta-analysis compared the ing that adapted ESTs may be as effective in effects of adapted versus non-adapted interven- international settings as they are found to be in tions for minority clients regarding mental health the USA where they were first developed. Yet, outcomes. Hall, Ibaraki, Huang, Marti, and Stice within the U.S., it is possible that less accultur- (2016) found 78 studies and included a total of ated clients may especially benefit from services 13,998 participants in the analyses. Almost all that are delivered in languages other than English. participants identified as non-White individuals The authors also observed that nearly all of the (95%): 29% identified as African American, 30% adapted interventions employed a “top-down” as Asian American or Asian, 26% as Hispanic/ approach by changing parts of a treatment origi- Latino(a), 4% as Native American/American nally designed and tested for other groups (Hall Indian/First Nations Canadian, 1% as of Arab et al., 2016). Although this approach has demon- descent, 5% as other groups of color, and 5% as strated effectiveness in promoting positive out- of White/European descent. Additionally, a rele- comes among minority clients, it may neglect vant amount (24%) of studies were conducted cultural-specific manifestations of psychopathol- outside the USA, with adaptations of cognitive- ogy (e.g., neck-induced panic among Cambodian behavior therapy (CBT) as the most commonly refugees, ataque de nervios—nervous attack— tested adaptation (36%). Authors found an over- among Latinos/as), values and beliefs around all effect size of g = 0.67, indicating that adapted treatment processes, and socially valid coping interventions outperformed other conditions pro- strategies. These factors significantly impact how moting better mental health outcomes among researchers and clinicians assess treatment out- minority clients. Also, adapted interventions comes. Therefore, it is unclear how effective the were found to be particularly effective in treating intervention is in addressing such presentations anxiety and depression symptoms (marginal and engaging minority clients. Despite the meth- mean = 0.76) compared to general psychopathol- odological limitations, the meta-analysis offers ogy (marginal mean = 0.48; Hall et al., 2016). important evidence that adapted treatments are Similar to the previous meta-analysis (Griner effective in reducing mental health symptoms & Smith, 2006), Hall et al. (2016) observed that among minority clients (Hall et al., 2016). certain factors would moderate the effect of In sum, the findings point to the complex pro- adapted interventions. Regarding the study cess of adapting treatments to be more culturally design, studies that compared the adapted inter- relevant and, consequently, engaging and effec- vention with no intervention yielded higher effect tively treating minority clients. Studies have sizes in favor of the adapted intervention (mar- pointed to multiple factors that may moderate ginal OR = 9.8). On the other hand, when the the effectiveness of adapted interventions among adapted interventions were compared with other diverse clients such as racial and ethnic group manualized treatment, the effect sizes were identification, acculturation level, and fluency in smaller (marginal OR = 3.47). This emphasizes English. Moreover, adapting interventions by the importance of employing rigorous method- including cultural values may not be sufficient to ological designs to accurately capture the effi- significantly increase client engagement and cacy of adapted interventions for minority clients. promote mental health outcomes, as it is essen- In terms of the client’s characteristics, the ethnic tial to understand how mental health issues may 8 Friend or Foe: Empirically Supported Treatments for Culturally Minority Clients 97

manifest and in which ways treatment processes group differences on these elements. Results may differ for minority clients. It is possible that showed significant ethnic group differences on they perceive, understand, and value treatment two of the three cultural elements: ethnic minor- components such as treatment goals and tech- ity clients reported that it is more important to niques differently, which then influence how have a therapist from the same racial background they engage in the therapeutic alliance and ben- and that the therapist is more knowledgeable of efit from treatment. In the next section, we will prejudices/discrimination experiences compared further explore distinct factors that may affect to Whites clients (Meyer & Zane, 2013). These relevant treatment processes for minority groups. preferences may influence how minority clients perceive and engage in mental health treatments. In fact, studies have shown that for a client Significance of Cultural Factors whose primary language was not English, racial in Treatment and ethnic match was associated with lower therapy attrition compared to clients whose primary As previously highlighted, the literature points language is English (Sue et al., 1991). The to the fact that minority clients may have unique authors found that same ethnic background and treatment experiences which significantly impact same language were significant predictors of their engagement and outcomes. For instance, a positive outcomes for those clients who were study found that participants who preferred to less proficient in English, pointing to the impor- speak a language other than English tended to tance of considering not only the client’s racial endorse an avoidant coping style compared to and ethnic background but also their language those who preferred to speak English (Kim, skills and acculturation level (Sue et al., 1991). Zane, & Blozis, 2012). An avoidant coping style These studies are extremely important to be con- was significantly associated with negative symp- sidered in the context of the USA where the toms and psychological discomfort after treat- majority of psychologists identify as White ment. Thus, preference for a different language (84%; American Psychological Association, was related to avoidant style which, in turn, was 2018). Although it may not be possible to always associated with poorer treatment outcomes. match client and therapist regarding their race These findings suggest that language preferences and ethnicity, research has shown that having a may not directly impact treatment outcomes, but therapist who speaks the client’s language has a this relationship may be mediated by specific positive effect on outcomes (Griner & Smith, factors such as coping styles, which are arguably 2006). By being aware of cultural factors that largely based on cultural values (Kim, Sherman, may impact treatment for minority clients, clini- & Taylor, 2008). In this case, treatments that cians can actively implement strategies to focus on direct coping styles and strategies may increase the relevance of interventions. not be sensitive to minority clients who employ In general, research indicates that culturally more avoidant coping styles as a result of cul- specific factors significantly influence how tural values and norms. minority clients perceive, value, and engage in It is also important to examine how the thera- different elements of the therapeutic process. pist’s cultural background may play a role on When these factors are not considered, they may treatment processes. Meyer and Zane (2013) negatively affect therapy processes and out- assessed three culture-specific elements—racial comes. Thus, understanding how to make mental match between client and therapist, care provid- health treatments more valid and engaging for er’s knowledge of prejudice or discrimination, minority clients is essential to better serve these and therapist’s ability or willingness to openly communities. In the next section, we will intro- discuss issues of race and ethnicity in treat- duce a conceptual model that provides a frame- ment—in a group of 102 clients in outpatient work to examine the influence of culture on mental health services and tested for ethnic treatment and treatment outcomes. 98 S. A. Nishioka et al.

Cultural Influences in Treatment: experienced in treatment and have an impact on The Proximal-Distal Model outcomes (Sue & Zane, 1987). By using the model as a framework to understand clinical When exploring the role of culture in treatment work with minority clients, researchers and cli- processes and client outcomes, it is important to nicians may identify and explore hypotheses identify the specific factors involved. There are related to how the client’s cultural background few conceptual models or clinical approaches may influence treatment. Moreover, based on that systematically articulate how cultural fac- this framework, adaptations and strategies can tors may affect the treatment process and out- be elaborated to better serve minority communi- comes. The proximal-distal model (Sue & Zane, ties. Treatment credibility is a robust predictor of 1987) provides one such framework to articulate treatment effectiveness and particularly impor- the effects of cultural differences in psychother- tant for minority clients (Kazdin & Wilcoxon, apy with minority clients. As the model shows 1976). The proximal-distal model has identified (Fig. 8.1), there is an interface between specific three domains that may negatively impact treat- cultural factors and important treatment pro- ment credibility: (1) problem conceptualization, cesses that cause and/or exacerbate the issues for (2) coping strategies and problem-solving, and these clients. For instance, cultural differences in (3) treatment goals (Huang & Zane, 2016). communication style between therapist and client could affect establishing an effective thera- Problem Conceptualization This domain peutic alliance. The cultural elements (e.g., refers to how the intervention conceptualizes or worldviews, help-seeking belief, communica- explains the client’s difficulties according to its tion styles) may affect key treatment processes theoretical orientation. The problem conceptual- (e.g., treatment credibility, client engagement, ization guides the therapeutic strategies that are self-disclosure, treatment goals), which in turn used and how the therapist will evaluate the out- affect treatment outcomes. Therefore, ethnic and comes. However, the client’s cultural beliefs and cultural variations between client and therapist values may shape how they perceive their mental may be examined in terms of distal variables health issues. The incongruence/discrepancy (e.g., communication styles) influencing more between therapist and client problem conceptual- proximal variables (e.g., self-disclosure) that are ization may negatively affect therapy process and

Fig. 8.1 Proximal-distal model (Adapted from Huang & Zane, 2016) 8 Friend or Foe: Empirically Supported Treatments for Culturally Minority Clients 99 results. For instance, Asian American clients, Guarnaccia, Lewis-Fernández, and Marano who tend to endorse that mind and body are (2003) interviewed 121 Puerto Ricans who had deeply interconnected, may emphasize more the experienced a cultural-specific condition, ataque role of somatic symptoms (e.g., headaches, stom- de nervios (i.e., nervous attack) following an achaches) in mental health compared to White environmental disaster in the island. Participants clients (Lin & Cheung, 1999). This may influ- described the condition as the combination of ence the credibility (i.e., the extent to which the social, emotional, and physical symptoms (e.g., client believes the therapist is effective, trustwor- no control over behaviors and emotions, tension, thy, and an expert to help them; Sue & Zane, loss of consciousness). The authors highlighted 1987) of clinical practices that do not include that Latino individuals often talk about nervios somatic symptoms and strategies to improve the (i.e., nerves) instead of mental health diagnoses client’s well-being. The tendency for some cli- because it is a more culturally meaningful con- ents, particularly ethnic minority clients, to cept. Additionally, suffering from nervios is express mental health symptoms somatically related to social causes such as familial trauma goes counter to more Western-based, cognitive and loss, which provides a cultural framework to perspectives of mental health, which conceptual- understand problems (Guarnaccia et al., 2003). ize mental health problems as a result of mal- Thus, factoring in somatic and physical presenta- adaptive cognitions rather than somatic tions in treatment may help minority clients, experiences. Therefore, the discrepancy between whose cultures emphasize the mind and body therapist and client conceptualizations of the connection, to better express their distress and mental health problem may diminish therapeutic address their concerns in culturally relevant alliance and treatment credibility. In fact, there is ways. ESTs that are structured and manualized evidence showing that agreement between thera- may not account for the cultural variations in pist and client regarding the perceived problem conceptualizing mental health problems. would predict short-term positive outcomes while controlling for client’s racial and ethnic back- Coping Strategies and Problem-Solving This ground (Zane et al., 2005). domain is defined by the potential cultural differences in coping and problem-solving strategies Minority clients may present and/or focus on between client and therapist. In order for ESTs to certain mental health issues according to their be more culturally relevant, they may need to pro- cultural values and perspectives. As previously pose clinical strategies that address mental health mentioned, Asian American as well as Latino cli- symptoms that are valid or normative according to ents tend to present more somatic symptoms the client’s cultural background. For example, compared to other groups (Flaskerud, 1986; Lin earlier studies have shown that Asian American & Cheung, 1999). These somatic complaints are clients prefer more directive, explicit, and prag- often culturally valid expressions of distress that matic therapeutic interventions compared to lead to less stigmatizing help-seeking behaviors White clients (Arkoff, 1959; Meredith, 1966). among minority populations (Hwang, Myers, Although some evidence-based approaches are Abe-Kim, & Ting, 2008). For example, Chinese more structured and solution-focused (e.g., cogni- patients diagnosed with depression tend to report tive-behavior therapy; CBT), they may also only somatic complaints and not mention emo- assume that the individual has the primary control tional complaints in their first visits to the psy- over their life events to implement these strategies chiatrist compared to White patients who would and do not consider the involvement of significant emphasize the emotional disturbances. This dif- others and the larger community (Iwamasa, Hsia, ference is thought to be related to the cultural ten- & Hinton, 2006). Minority clients who come from dency to not disclose emotional distress to others more collectivistic cultures, such as Asian and as well as the high prevalence of mental health Latino cultures, may find this individualistic stigma in Asian cultures (Hwang et al., 2008). approach inappropriate or incongruent with their 100 S. A. Nishioka et al. beliefs regarding the involvement of family and and seek help from their religious community the respect for elders. In this case, a client from a (87.1% vs 74.2%, p < 0.01). Moreover, African more collectivistic culture may find interventions American students endorsed more external that focus exclusively on the individual as less rel- sources of control (e.g., God, powerful others, evant and, consequently, benefit less from it. chance) as explanations for their psychological symptoms than White students (Ayalon & Young, Research has found that minority individuals 2005). These results suggest that for this minority may endorse different coping strategies to address group, religious beliefs have a significant role in stress and interpersonal conflicts compared to understanding and coping with psychological White individuals (Lam & Zane, 2004). A study stress. Not accounting for these factors may neg- examined the coping styles of Asian and White atively impact trust and alliance in the therapeu- Americans and observed significant differences tic work. Indeed, research has pointed to the between the two groups. White participants importance of incorporating spirituality into endorsed more strategies such as changing the treatment with African American clients since it nature of the stressor (i.e., primary control). is a salient cultural value (Snowden, 2001). Conversely, Asian participants endorsed more By being aware of cultural differences in cop- strategies that change how they feel and think ing strategies, clinicians can incorporate the cli- about the stressor (i.e., secondary control). The ent’s orientation into treatment to improve results suggest that an intervention that focuses engagement and outcomes. For instance, clients mainly on primary control may be less relevant who shared the same coping orientation (e.g., for Asian clients who are less oriented towards avoidant coping style) with their therapists at pre- this type of coping strategy. In fact, authors found test reported less discomfort and less depressive that orientation towards the individual’s indepen- symptoms after four sessions compared to a cli- dence fully mediated the ethnic difference in pref- ent who did not share the same coping orientation erence for primary control. White participants with their therapists (Zane et al., 2005). The find- were significantly more oriented towards individ- ings point to the effect of cultural variance in ual independence compared to Asian participants, coping and problem-solving orientation. and those participants who were more indepen- Interventions that endorse strategies that are not dence-oriented also endorsed more primary con- culturally acceptable or congruent with the cli- trol (Lam & Zane, 2004). Considering that many ent’s values may have less effect on treatment psychological interventions were developed and outcomes for minority clients. tested in the context of Western culture that emphasizes independence, self-reliance, and Treatment Goals This domain highlights the autonomy (Markus & Kitayama, 1991), the rec- importance of clients’ perceptions about therapy ommended coping strategies tend to reproduce goals and outcomes, which may vary from those these values emphasizing independence and pri- identified by the therapist. Early studies have shown mary control over interdependence and secondary that East Asian and Western psychotherapies control. For minority clients who are less oriented diverge from what they consider as the treatment towards Western values, this approach can be less primary goal (Murase & Johnson, 1974). While socially acceptable or applicable to their lives. East Asian therapies emphasize recovery and Another study compared coping strategies improvement of the client’s roles in society, such as endorsed by African American and White com- being a good worker or fulfilling their role as a par- munity college students (Ayalon & Young, 2005). ent or spouse, Western therapies emphasize reduc- The authors observed that African American stu- tion of client’s stress related to their life or identity. dents reported less use of psychological services This comparison clarifies the underlying social val- compared to their White counterparts (34.3% vs ues that shape how therapy may be perceived by 53%). On the other hand, the former group was minority clients. According to the proximal-distal more likely to endorse spiritual coping strategies model, there may be dissonance between a client’s 8 Friend or Foe: Empirically Supported Treatments for Culturally Minority Clients 101 expectations of the treatment and the actual pro- In addition to the three domains mentioned posed treatment (by the therapist) due to relevant above, there are other cultural factors that may cultural differences that will ultimately affect the directly impact the credibility of ESTs among effectiveness of the intervention for certain groups. minority clients. For instance, a minority client who is oriented towards rehabilitation to their social roles may per- Cultural Identity The literature has demon- ceive a treatment that focuses on reducing stress to strated that African American clients tend to mis- be ineffective because the client’s primary goals trust mental health services, especially when the with treatment are not aligned with the goals of that therapist is White (Cabral & Smith, 2011; treatment. Research found that when clients and Whaley, 2001). In fact, as discussed before, therapists had similar treatment goals, clients tended African American patients tend to be overdiag- to report better outcomes compared to when the nosed and overrepresented in inpatient units (Sue goals differed (Zane et al., 2005). Moreover, when et al., 1991). Whaley (2001) conducted a system- there was agreement on treatment goals, clients atic review focusing on cultural mistrust, or skep- reported perceiving their sessions as more impact- tic attitudes and beliefs towards White individuals ful, feeling more comfortable in sessions, and hav- including therapists, in the context of mental ing more positive perceptions about the work in the health services. The author examined 22 studies sessions. and found a moderate effect size (r = 0.303), indicating that African American clients experience Family support and cohesion are also salient cultural mistrust in therapy as they experience in aspects of Latino culture. Domenech Rodríguez, other social interactions (Whaley, 2001). Client’s Baumann, and Schwartz (2011) described the attitudes towards the therapist may explain some systematic adaptation of a parenting interven- barriers to building an effective therapeutic alli- tion for Latino families. During focus groups, ance with minority clients. Particularly for participants identifiedsuperación (i.e., the African American communities, having a White child going beyond the parents’ achievements) therapist may increase their cultural mistrust in and educación (i.e., the child being competent therapy and hinder treatment outcomes. and respectful toward adults) as important parenting goals within their culture. The cultural Besides the therapist racial/ethnic identity, value of respect (i.e., respect to elders) was their therapeutic style (e.g., more or less direc- underscored as another relevant factor shaping tive) may be perceived in a variety of ways family interactions. After identifying these con- affecting the treatment process. Wong, Beutler, cepts associated with parenting, the authors and Zane (2007) conducted an experiment to framed the treatment goals in a more culturally test how ethnicity would influence perceptions valid way. For instance, parental encourage- of therapist credibility (i.e., how credible and ment was linked to promotion of educación and effective they found the therapist) depending respecto. The adaptations were effective in on the therapeutic style used. Asian and White retaining families longer in the intervention and American participants observed expert thera- promoting positive parenting behaviors (e.g., pists using a directive or nondirective approach limit setting) at comparable rates with other in a therapy session and reported on their reac- samples (Domenech Rodríguez et al., 2011). tions to the therapists. Results showed that The results suggest that framing treatment Asian American participants rated the nondi- goals and interventions according to the client’s rective sessions lower in credibility and work- cultural values can significantly increase treating alliance compared with White participants. ment engagement. Additionally, Asian American participants The proximal-distal model provides a frame- found that nondirective therapists were less work to investigate and assess the effect of cul- easy to understand, and this perception was tural factors on treatment processes and outcomes. significantly associated with lower rates of 102 S. A. Nishioka et al. intervention credibility as well (Wong et al., Face Concern Face has been defined as an indi- 2007). In this case, the minority (i.e., Asian vidual’s set of claims about their character and American) clients’ perspectives of their thera- integrity that are socially sanctioned and defined pists were negatively impacted by their treat- based on roles that the individual is expected to ment approach preference (i.e., directive over fulfill as a member of a certain group (Zane & Yeh, nondirective). These perceptions may, in turn, 2002). This concept was previously identified as negatively impact their treatment responses or playing an important role in defining interpersonal outcomes. dynamics in Asian social relations and, conse- Similar results were observed in a study that quently, associated with help-seeking behaviors compared the credibility of two ESTs, cognitive (Shon & Ja, 1982; Sue & Morishima, 1982). In therapy and time-limited dynamic psychother- Asian interpersonal relations, individuals are apy, among Asian American participants (Wong, expected to behave in a certain way in order to Kim, Zane, Kim, & Huang, 2003). Participants avoid losing face. This is problematic, since com- were randomly assigned to read about one of the mon treatment processes that characterize Western approaches for treating depression and reported psychotherapies, such as diagnosis of mental on their perceptions of treatment credibility. health symptoms and self-disclosure of personal Findings showed that Asian American partici- experiences, may elicit negative reactions in indi- pants with lower levels of White identity per- viduals concerned with losing face. Stigma and ceived cognitive therapy to be more credible than stereotypes around mental illnesses are a signifi- dynamic therapy. On the other hand, Asian cant barrier to seeking treatment for many minor- American participants with higher levels of ity groups (Gary, 2005). For instance, among White identity did not perceive the two Chinese immigrants, stigma towards mental ill- approaches differently (Wong et al., 2003). nesses is higher when it is associated with the indi- A mixed-methods study examined differences vidual’s inability to work and be productive in in therapeutic styles between Latino and non- society (Yang et al., 2014). That is, having a diag- Latino clinicians (Lu, Organista, Manzo, Wong, nosis of mental illness may be perceived as failing & Phung, 2001). Participants rated their style to fulfill important social roles (e.g., work) or los- according to three primary domains: direct, ing face, which subsequently decreases the chance instrumental, and relational. The authors found of the individual seeking help. Furthermore, a core that Latino clinicians endorsed less direct and part of psychotherapies (such as CBT) requires instrumental styles and more relational styles clients to self-disclose their thoughts and emo- compared to non-Latino clinicians. Interviews tions. Self-disclosure may be an issue for minority with the clinicians supported these findings; clients whose cultures value privacy and limited Latino clinicians emphasized that developing a exposure of problems to strangers, especially strong relationship with Latino clients and their when related to interpersonal issues. For instance, families is crucial for treatment engagement (Lu self-disclosing about problems or conflicts with et al., 2001). Reinforcing this view, Perez (1999) other people may evoke feelings of shame in argues that therapists could integrate components minority clients who could be concerned about of interpersonal therapy (IPT)—which focuses saving face. As a result, concerns about face loss on restoring interpersonal relations—into con- may significantly influence treatment processes ventional cognitive-behavior therapy (CBT) to such as establishing a positive therapeutic relation- make it more relevant and effective for Latino ship, engaging the client in treatment, and using communities. Overall, the research highlights therapeutic strategies. that cultural factors such as ethnicity, cultural identity, and endorsement of Western values may As observed, face loss may be an important con- moderate treatment credibility, which, in turn, cept to understand the unique experience of minor- may affect treatment engagement and its effects ity clients in the context of psychological treatment. on mental health. Zane and Yeh (2002) developed and validated the 8 Friend or Foe: Empirically Supported Treatments for Culturally Minority Clients 103

Face Loss Questionnaire comprised of 21 items affect therapy processes, such as face concern, to assessing the extent to which the responder is con- better address minority clients’ needs. cerned about face. The measure was tested with White and Asian American participants yielding Racial and Ethnic Match Between Therapist high levels of reliability α = 0.83 (Zane & Yeh, and Client Having a diverse staff in mental 2002). Additionally, the authors found that face health clinics and agencies can be attractive to concern was positively correlated with concerns minority clients and reflect the diversity in the about others, private self-consciousness, and public communities themselves. Nevertheless, as men- self-consciousness, and negatively correlated with tioned above, matching therapist and client racial extraversion, tendency to perform before others, and/or ethnic background (i.e., racial and ethnic and White cultural identity. Importantly, ethnic dif- match) may not directly translate into more cul- ferences were observed regarding levels of face turally competent services (Flaskerud, 1986; Sue, concern; Asian American participants reported 1977). Meta-analyses (Cabral & Smith, 2011; higher levels of face concern compared to White Maramba & Nagayama Hall, 2002) have Americans (Zane & Yeh, 2002). reviewed the effects of the racial and ethnic Research using this instrument has shown that match between therapist and client on treatment individuals who are highly concerned with face outcomes and dropout rates. It was often expected tend to be less inclined to self-disclose their per- that minority clients who shared similar cultural sonal values/feelings, private habits, close rela- backgrounds with their therapists would benefit tionships, and sexual issues (Zane & Ku, 2014). more from therapy and have lower dropout rates Moreover, the authors tested the effect of gender compared to minority clients who had a therapist and ethnic match between therapist and client on from a different background. In fact, Maramba the levels of self-disclosure. They found that gen- and Nagayama Hall (2002) found significant but der match improved disclosure of sexual issues small effect sizes for treatment utilization while the ethnic match did not increase self- (r = 0.04, p < 0.001) and dropout (r = 0.04, disclosure, indicating that clients who are con- p < 0.001) rates when therapist and client were cerned about losing face do not benefit from ethnically matched. Moreover, the effect sizes having a therapist from the same ethnic back- were significantly larger for ethnic minority cli- ground to increase self-disclosure (Zane & Ku, ents compared to White clients. That is, the racial 2014). This is possibly because clients will and ethnic match is particularly beneficial for attempt to save face irrespective of their conver- minority clients. On the other hand, when analyz- sational/interactional partner. ing treatment outcomes at termination, the Another study examined the impact of face authors did not find significant differences concerns on treatment credibility (Park, Kim, & between clients who had ethnic matched thera- Zane, 2019). Results showed that minority par- pists and those who did not (r = 0.01, p > 0.05; ticipants who reported higher levels of face con- Maramba & Nagayama Hall, 2002). Possibly, the cern preferred a more directive therapist. That is, match has stronger effects in the beginning of the face concern moderates the participants’ prefer- treatment when cultural differences may lead to ences on the therapist’s counseling style. A pos- early dropout or poor therapeutic alliance. Once sible explanation is that those who are more the work alliance and treatment goals are estab- concerned about face social roles may see the lished, ethnic match may have a smaller effect. therapist as an authority figure from whom they receive advice and directives. In this sense, a Another meta-analysis found similar results. therapist whose style is less directive may be also Cabral and Smith (2011) calculated the effect seen as less credible, as it becomes unclear to cer- sizes of 52 studies investigating the client’s pref- tain minority clients the roles and structure of the erences for a therapist from the same race/ethnic- treatment. These results highlight the importance ity. Results showed that clients tended to have a of understanding the specific cultural factors that moderately strong preference for a therapist of 104 S. A. Nishioka et al. the same racial/ethnic background (r = 0.63, White clients. ESTs that do not consider the p < 0.001). However, when it came to therapeutic experiences and values of minority clients may outcomes, the authors found small effect sizes not be as effective for these populations. (r = 0.09, p < 0.001) indicating that there was a Furthermore, these treatments may unintention- small difference between clients working with ally perpetuate disparities in mental health by matched therapists versus unmatched therapists. offering interventions that may not be valid for Examining preferences across racial groups, the minority clients. These limitations of ESTs in authors observed significant differences: African addressing minority clients’ needs are even more American participants reported higher prefer- pronounced when we consider culturally relevant ences (d = 0.88) for matched therapists compared treatments for minority adolescents and children. to other groups (Asian Americans d = 0.28; In the next section, the available literature in this Hispanic/Latino Americans d = 0.62; White/ area is presented to highlight ways that minority European Americans d = 0.26; p = 0.03; Cabral & youth and their families may particularly benefit Smith, 2011). This finding suggests that for from ESTs that account for their context and cul- African American clients, the racial and ethnic tural background. match between therapist and client is more salient than for other minority clients. Thompson and Alexander (2006) randomly Empirically Supported Treatments assigned 44 African American clients to either an for Minority Adolescents African American or a White therapist. Therapy and Children modality (i.e., problem-solving and interpersonal) was also randomly assigned and controlled Research has shown that adolescents and chil- through close supervision of each session. After dren from diverse backgrounds have similar or treatment (i.e., maximum of 10 sessions), clients even higher mental health needs compared to rated their symptom levels and perceptions about their non-Hispanic White peers (Georgiades, therapy. Results showed no moderation of racial Paksarian, Rudolph, & Merikangas, 2018). For match on therapy outcomes. However, clients instance, a study analyzed data from more than who had an African American therapist had sig- 6000 adolescents ages 13–18 years and found nificantly higher ratings of understanding and that minority teens were as likely as their White acceptance of treatment goals and strategies peers to develop mood or anxiety disorders while controlling for therapy modality (Hispanic: AOR = 1.30; non-Hispanic Black: (Thompson & Alexander, 2006). These studies AOR = 1.14; Asian: AOR = 1.07, ps > 0.05). underscore that African American clients may However, when looking at service use rates, benefit more from sharing their racial/ethnic minority youth were significantly less likely to background with their therapist compared to receive mental health treatments compared with other minority groups. As discussed in previous their White counterparts (Hispanic: AOR = 0.7; sections, this may be related to cultural mistrust non-Hispanic Black: AOR = 0.54, ps < 0.01; (Whaley, 2001). Thus, culturally sensitive ESTs Asian: AOR = 0.8, p > 0.05; Georgiades et al., should consider the particularities of the commu- 2018). These findings suggest that although nities and integrate them into treatment to maxi- minority youth experience the same levels of mize outcomes. mental health problems as their White counter- The literature on cultural factors, as high- parts, they do not engage in treatment as much, lighted by the proximal-distal model, points to possibly, because of significant barriers to access the critical fact that minority clients may perceive these services. Moreover, youth depend on their and value different aspects of their therapist and parents/caregivers to access services (Stiffman, therapy approaches compared to White clients. Pescosolido, & Cabassa, 2004). In minority fami- Such differences may not be explicit in ESTs that lies, caregivers may have limited English fluency are, overall, developed for and tested mainly with to understand and interact with the health system, 8 Friend or Foe: Empirically Supported Treatments for Culturally Minority Clients 105 have concerns about their immigration status, that are not accounted for in “lab” settings (Huey and lack insurance coverage to utilize services & Polo, 2008). preventing youth from receiving treatment Another systematic review conducted by (Georgiades et al., 2018; McGee & Claudio, Jackson (2009) focused on evaluating culturally 2018). Thus, it is particularly important to engage sensitive prevention interventions for minority minority adolescents, children, and their parents/ youth. Using the California Evidence-Based caregivers in mental health treatments that effec- Clearinghouse’s Scientific Rating Scale (CEBC, tively address their difficulties and foster a 2007), which is a systematic method to evaluate healthy development. the extend of evidence supporting an interven- Nevertheless, there is a lack of methodologi- tion, the author classified the various studies cally sound research studies that evaluate the using a range. The classification ranged from effectiveness of interventions among minority level 1—Superior, which describes research adolescents and children. One of the few system- employing experimental designs with an equiva- atic reviews examining the evidence supporting lent control and comparison group, to level 5— mental health treatments for minority youth was concerning, which describes no evidence of conducted by Huey and Polo (2008). The authors positive change. The author examined 15 studies aimed to identify ESTs targeting behavioral and and found that eight of them were at level 3— emotional problems among adolescents and chil- efficacious, as the interventions demonstrated dren. The meta-analysis included 25 different efficacy over the control group or comparable to control trials yielding an overall moderate effect another intervention in quasi-experimental stud- size of d = 0.44 (SE = 0.06) at posttreatment. ies. Four interventions were classified as level Overall, the results support the effectiveness of 2—effective. That is, they employed an experi- ESTs for minority youth favoring their imple- mental design with random assignment to condi- mentation to address mental health issues (Huey tions and observed a significant reduction in the & Polo, 2008). target behavior among the participants assigned The authors also analyzed the difference to the intervention condition (Jackson, 2009). In between culturally enhanced interventions in general, these results suggest that there is empir- comparison to regular ones (Huey & Polo, 2008). ical support for ESTs for minority youth. The evidence was not consistent in supporting However, there is an urgent need for further the idea that culturally enhanced interventions research in this area including experimental promote better outcomes compared to non- designs and larger youth samples from different adapted interventions. Such findings may be due racial and ethnic backgrounds to clearly identify to the small sample sizes in the studies and the culturally relevant treatments for this population. inaccuracy in measuring and assessing the qual- Moreover, research should focus on the specific ity of the cultural adaptation that was used (Huey factors that are implicated in treatment processes & Polo, 2008). Yet, the authors highlight the and outcomes for minority adolescents and chil- importance of considering the family’s values dren. As highlighted in previous sections, studies when tailoring interventions to the youth’s social including adult samples are growing in number and cultural context. It is particularly important and yielding important results to guide interven- to identify individual factors (e.g., ethnic identity, tions. In the same way, studies including youth developmental level, gender) that are signifi- samples must increase in number to provide cantly related to treatment processes and can clearer data about effective interventions and guide how interventions are translated to “real salient factors affecting mental health outcomes. world” settings. That is, researchers should focus In the next section, considerations of limitations on how ESTs are implemented in minority com- in this field and future directions for research are munities that face a variety of barriers to services presented. 106 S. A. Nishioka et al.

Limitations and Future Directions intervention. However, there is a lack of evidence regarding whether the selected cultural values are There are important limitations in the evaluation associated with increasing treatment credibility research that has been conducted particularly in the target population. One possible systematic regarding the effectiveness of culturally adapted approach to cultural adaptations is Kazdin’s interventions for minority populations. Often, the (1977) conceptualization of the social validity of culturally adapted intervention is compared to the treatments. This conceptual model supports the non-adapted intervention for the same community idea that diverse groups may hold unique percep- in terms of treatment outcomes. When the results tions, understanding, and acceptability levels of of these studies show that the culturally adapted mental health treatments which significantly intervention is as effective as the non-adapted impact how they engage in them. The framework intervention, there is a tendency to conclude that encouraged further work, such as the develop- the non-adapted one should be preferred, since ment of assessment tools of treatment social there is no difference between them. However, the validity (Reimers & Wacker, 1988) that, in turn, results could be interpreted as showing that the can inform the adaptation process of interven- adapted intervention is in fact as effective as the tions. Based on ratings of social validity and the original intervention suggesting the former holds consideration of the specific components that are the therapeutic components of the latter. Moreover, not socially valid, researchers can more accu- given they have the same effects, the adapted rately modify interventions that will be more cul- intervention should be preferred over the non- turally informed and relevant. adapted one because it is more socially valid for the target community by incorporating cultural aspects while maintaining similar effectiveness. Conclusions Research aiming to better evaluate the effects of ESTs for minority clients may benefit from the For cultural minority clients, mental health dis- critical process approach (CPA; Zane, Kim, parities involve critical problems and difficulties Bernal, & Gotuaco, 2016), as it offers a system- in access, engagement, and benefit from psycho- atic guideline to adapt interventions for minority logical interventions. This review indicates that clients and identify critical treatment components cultural factors influence treatment and may that can be tailored to the specific population. challenge the implementation of ESTs with Therefore, evaluation studies may test the effects minority clients. There are a multitude of cultural of specific variables and determine the equiva- issues that may affect the treatment experience of lency between adapted and non-adapted interven- these clients. However, the pressing and continu- tions. Again, the adapted intervention should be ing challenge for clinicians centers on how to seen/acknowledged to be as effective as the non- systematically apply this empirically based adapted intervention and not necessarily superior knowledge to provide culturally competent care. to it. This approach may be extremely positive for We propose the proximal-distal model as one advancing the field and disseminating the use of promising and practical strategy in which clini- ESTs for minority populations. cians can generate and test working hypotheses Nonetheless, there are other significant chal- to enhance the treatment impact and experience lenges particularly related to the lack of theoreti- for minority clients by addressing specific cul- cal models that support the adaptation of tural issues that may mitigate certain treatment interventions while considering relevant treat- processes and outcomes. In this approach, the ment processes and outcomes. Few researchers major premise nominates treatment credibility as employ a bottom-up approach when adapting an the primary treatment process that cultural issues intervention for a specific population (Hall et al., often adversely affect which, in turn, negatively 2016). Most of the studies select cultural values impacts treatment outcomes. Treatment credibil- that they consider relevant to integrate in the ity is a critical treatment process that has been 8 Friend or Foe: Empirically Supported Treatments for Culturally Minority Clients 107 linked to treatment outcomes, (Kazdin & tice. This model is promising, but it is not the Wilcoxon, 1976) as well as treatment utilization only one available. Hwang’s (2006) psychother- (Kim & Zane, 2016). Clinicians can generate apy adaptation and modification framework working hypotheses as to how a certain cultural (PAMF) was developed to help clinical research- issue may affect credibility. For example, there is ers adapt ESTs for ethnic minority clients and for evidence that minority clients may benefit from training mental health professionals. This frame- racial/ethnic match with their therapist (e.g., work includes four domains to assist in the adap- Cabral & Smith, 2011), particularly African tation of ESTs, including (1) dynamic issues and American clients. However, ethnic mismatches cultural complexities (i.e., awareness of clients’ between White therapists and African American identities and group membership), (2) orientation clients often occur. In these cases, some research (e.g., how they orient therapy, treatment goals suggests that White clinicians should hypothesize and structure, beliefs about disease develop- that cultural mistrust may be a significant barrier ment), (3) cultural beliefs (e.g., cultural bridging to developing an effective therapeutic alliance to relate treatment concepts to clients), and (4) with African American clients (Whaley, 2001). client-therapist relationships (e.g., understand Failure to do so may contribute to serious prob- how client’s cultural beliefs influenced their help lems in the therapist’s credibility. On the other seeking, clearly address client-therapist roles and hand, for certain Asian American clients, face expectations). More frameworks like the PAMF and shame issues may hinder the necessary and and proximal-distal model are needed to facili- critical process of open self-disclosure in treat- tate the development of “friendly” ESTs for ment (Zane & Ku, 2014). To maintain their cred- minority clients. ibility and influence in treatment, clinicians may Another way to identify “friendly” ESTs is to need to use specific face restoration strategies, diversify our research in this field. Many forms of such as encouraging clients to problem-solve to interventions may already exist that are indige- demonstrate their mastery and control. Similarly, nous to communities of color, or originate from there is evidence to indicate that folding in the the countries from which minority clients emi- value of respecto (i.e., respect) when working grated. For example, a recent review of literature with Latino families may significantly enhance found that tai chi was effective at decreasing the therapist’s credibility and the client’s engage- depression symptoms for Asian clients (Berger, ment in treatment (Bernal & Rodríguez, 2012). Huang, & Zane, in press). Another study found a Clinicians may hypothesize that this approach Lishi intervention to be effective at promoting may be more valid and have more credibility with treatment engagement and mental health out- their clients than a more traditional one that comes in a sample of Southeast Asian elderly frames problems as mental health disorders. As adults (Huang et al., in press). Since ESTs are such, they may frame familial conflict in terms of anchored in mainstream, White culture, includ- a lack of respect and offer strategies to solve ing indigenous treatments in EST research may these interpersonal problems. propel the field in ways that benefit minority ESTs have shown positive effects among communities. minority populations, yet challenges remain in Finally, researchers should be examining truly determining if they are “friend” or “foe” for their own practices and policies in how they minority clients. For one, ESTs are developed approach and describe issues of diversity. from the Western, predominately White main- Currently, the general practice is for researchers stream perspective, and even the adaptation of to describe how their research findings may be these interventions is still taking the mainstream generalizable to minority populations. If the perspective and applying it to minority communi- intention of creating “friendly” ESTs is truly ties (i.e., top-down process). The use of frame- serious, researchers should be more explicit works such as the proximal-distal model can help about how their treatment may only be applica- guide the process of translating research to prac- ble to Whites and how it may be limited for other 108 S. A. Nishioka et al. groups. This will allow other researchers to build in a Latino/a community context. American Journal of Community Psychology, 47(1–2), 170–186. upon those limitations and design studies that Flaskerud, J. H. (1986). 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Monnica T. Williams, Jamilah R. George, and Destiny M. B. Printz

Introduction As such, African Americans disproportionately represent some of the most vulnerable popula- Behavioral health is a broad term which gener- tions, including poor, homeless, incarcerated, and ally describes the ways in which behavior, health, foster care recipients at rates higher than Whites or and the well-being of the body, mind, and spirit any other ethnic minority group (U.S. Department are connected. Behavioral health services often of Health and Human Services [HHS], 2001). encompass treatment, intervention, and preven- African Americans also live with experiences of tion of medical diagnoses and disorders such as everyday discrimination and racism which has substance abuse and other addiction, eating and negative effects on both their physical and mental drinking habits, and in recent years it includes all health (HHS, 2001; Jackson et al., 1996; Kwate & forms of mental health. Considering that 1 in 5 Goodman, 2015). As a result, they are less likely to adults in the USA experiences mental illness in a receive care and more likely to endure untreated given year (National Institute of Mental Health symptoms and prolonged suffering. [NIMH], 2016), it is important for mental health The USA is now more culturally diverse than specialists to think critically about the ways in it has ever been and will only continue to become which behavioral health services are delivered, increasingly so. By 2060, the Black US popula- particularly to underserved and consequentially tion will increase from the current approximate at-risk populations. One such group is African 41.2 million to 61.8 million, increasing the total Americans—who, despite recent attempts to Black population by 1.6% (U.S. Census Bureau, advance mental health services for ethnic minor- 2016). These statistics point to the urgency of ity groups, continually receive inadequate and improving the delivery of behavioral health ser- inferior mental health care. vices to ethnic minorities in general, but for the Though African Americans do not experience purpose of this chapter, specifically to African greater prevalence of mental health conditions in Americans and people of African descent. comparison to the rest of the population (Primm, The term African American is most commonly 2006), their mental health symptoms are often used to describe people of African descent living exacerbated by external factors such as discrimi- in the USA; however, this group is comprised of nation, homelessness, abuse, trauma, and poverty. different cultures and origins, and is becoming increasingly more diverse itself. Other diasporic M. T. Williams (*) · J. R. George · D. M. B. Printz groups tend to be more recently included among Department of Psychological Sciences, University of Black Americans, such as immigrants, refugees, Connecticut, Storrs, CT, USA descendants of the Caribbean, and African e-mail: [email protected]

© Springer Nature Switzerland AG 2020 111 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_9 112 M. T. Williams et al. nations. So not all Black people are African comparison to European Americans (Atkins- American (ethnic group), but all African Loria, Macdonald, & Mitterling, 2015). Although Americans are considered Black (racial group). research has indicated few differences in preva- Because of the pervasive negative stereotypes lence rates, this is likely due to investigative pro- about African Americans and the awful cultural tocols’ emphasis on precise diagnostics, as history of subjugation and enslavement, many clinical settings show a large gap in race-based Black immigrants are reluctant to identify with diagnostic disparities. Further research is needed the African American label and feel very distinct to determine the extent to which this discrepancy culturally. Many Black immigrants generally is due to misdiagnosis or actual variations in psy- have better mental health than African Americans, chopathology between racial groups (Liang, although the longer they live in the USA, the Matheson, & Douglas, 2016); however, numer- worse their mental health becomes (e.g., Soto, ous social and cultural influences have been indi- Dawson-Andoh, & BeLue, 2011; Williams et al., cated as contributors, including differences in 2007). Given the diversity of Blacks in America symptom expression (Chapman, DeLapp, and and the historical and cultural factors that com- Williams, 2018). As proper diagnosis is impera- plicate their mental health and psychiatric experi- tive to accessing appropriate treatment, it is ence, this chapter does not have the means to essential that health professionals accurately address the mental health issues of all Black identify symptoms and understand social/cultural Americans. We will be focusing on African impacts on the assessment of disordered symp- Americans, in reference to people of African her- toms in African American clients. The following itage who reside in the USA and are socialized sections discuss diagnostic considerations for into American culture. Correspondingly, non- disorders in which African Americans are over or Hispanic White people in the USA will be under represented. referred to here as European Americans. This chapter will highlight the complex influence of cultural, historical, and experiential fac- Psychotic Disorders tors on mental disorders in African American communities. We will begin with a review of dis- Psychotic disorders are possibly one of the most parities in diagnosis and variation of symptom- studied mental health diagnosis disparities in atology in several mental disorders among African Americans. African Americans may be African Americans in comparison to European four to five times more likely than European Americans. We will then discuss some of the bar- Americans to receive the diagnosis of schizo- riers often present in the face of treatment, and phrenia (DeCoux Hampton, 2007). When severe consider key components for facilitating treat- mental illness is present, African American youth ment with African Americans. Next, we will in an inpatient setting are more frequently diag- review practices for increasing clinician efficacy nosed with schizophrenia (Liang et al., 2016) and with African American clients. We will then con- adults are more likely to have their previous diag- clude with recommended resources and future nosis changed to schizophrenia, as well as to directions that will lead to the delivery of quality retain the diagnosis after completing care. and accessible behavioral health services for Additionally, African Americans born in the USA African Americans. are more likely than European Americans to be admitted to a psychiatric hospital (Snowden, Hastings, & Alvidrez, 2009), and rates of overdi- Misdiagnosis and Symptom agnosis can increase when African Americans are Differences assessed by a clinician as opposed to self-report measures (DeCoux Hampton, 2007). A contribu- Past and current prevalence rates across various tion to the difference in symptom ratings between mental health disorders illustrate both the over clinicians and patients may be cultural mistrust and underdiagnosis of African Americans in or healthy cultural paranoia. African Americans’ 9 Behavioral Health Service Delivery with African Americans 113 knowledge of historical and current subjugation Americans’ underutilization of outpatient mental and maltreatment in medicine may cause severely health care and increased symptom severity, mental ill patients to distrust European American including depressive psychosis, upon accessing providers and appear more paranoid to clinicians inpatient care (DeCoux Hampton, 2007). Poor (Whaley, 2001; Whaley, 2004); however, it is provider–client communication could also be to important for providers to understand the real- blame, as clinicians are more likely to downplay world context in which cultural mistrust is rooted. (Das, Olfson, Mccurtis, & Weissman, 2006) or Cases of providers using deception to harm misattribute African Americans’ mood symp- African Americans are numerous, from kidnap- toms (i.e., psychomotor retardation mistaken for ping freed-slaves for experimental dissections to loafing; DeCoux Hampton, 2007). African the continued involuntary sterilization of girls Americans lowered likelihood of initiating con- and women (Suite, La Bril, Primm, & Harrison- versations about depressed mood and differential Ross, 2007). The most widely known abuse may mood symptom expression due to cultural values/ be the U.S. Public Health Service Syphilis Study norms may also contribute to diagnostic diffi- at Tuskegee (1932–1972) experiments, in which culty (Baker, 2001; Walton & Payne, 2016). physicians mislead African American men with Baker (2001) outlined three differential expres- syphilis about their study participation with the sions of depression in African Americans: (1) intention to continually withhold curative treat- “The John Henry doer,” who may work exces- ment so their corpses could be examined (Centers sively to the detriment of their health due to unre- for Disease Control and Prevention [CDC], 2017; alistic standards for self and others, (2) “the stoic Hunter & Schmidt, 2010). With collective narra- believer” characterized by the minimization of tive surrounding recent and long-standing pro- depressive symptoms due to religious devotion, vider dishonesty, there may be little surprise that and the (3) “angry ‘evil’ one” who exhibits African Americans with severe mental illness increased agitation, curtness, and anger, which may prefer providers of the same race and have may increase clients’ risk of dysregulated or self- increased paranoid schizophrenia diagnoses, destructive behavior. When assessing depressive even when controlling for symptomology mood symptoms in African Americans, differen- (Whaley, 2001). Further, experiences of racism tial cultural presentations and efforts to improve may contribute to the development of psychotic communication and validation of symptoms disorders. A review article by Berger and Sarnyai should be considered. (2015) integrated correlational and longitudinal Although African Americans may minimize data demonstrating that experiences of racism or express depressive mood symptoms differ- may increase psychotic symptoms in people of ently, they are equally as likely to mention disor- color. This further reflects the importance of cul- dered symptoms within primary care settings as tural perspective in the diagnosis of psychotic European Americans. These discussions of disorders. depressive symptoms often surround neuroveg- etative and somatic symptoms (Das et al., 2006; DeCoux Hampton, 2007), making it increasingly Major Depressive Disorder difficult and important for clinicians to correctly identify the physical symptoms of depression in Major depressive disorder (MDD) may be under- African Americans. Such symptoms often diagnosed in African Americans, and despite lon- reported in African Americans with depression ger depressive episodes, African Americans are reduced appetite, insomnia, psychomotor receive less adequate treatment than European impairment, pain, and poor overall health (Das Americans (DeCoux Hampton, 2007; Walton & et al., 2006; DeCoux Hampton, 2007). Payne Payne, 2016; Williams et al., 2007). Misdiagnosis (2014) conducted a study with 218 licensed and underdiagnosis can be impacted by African masters-level therapists to understand how client 114 M. T. Williams et al. race may impact clinicians’ diagnosis. The study ences of racism in African Americans (Soto et al., showed clinicians one of four videos, two with 2011), as the unpredictable nature of discrimina- an African American or European American tion may be particularly anxiety-inducing. male client displaying classic depressive symptoms, and the other two displaying some of the aforementioned culturally influenced symptoms Obsessive-Compulsive Disorder of depression in African Americans. The symptoms expressed in all four videos were designed OCD is a quite heterogeneous disorder, and mis- to meet criteria for MDD only; however, when diagnosis is common among African Americans clients expressed culturally influenced symp- because patients who do not meet the most com- toms, regardless of client race, clinicians were mon OCD presentations (i.e., contamination much less likely to diagnose depression (68% vs fears and overt repetitive checking) may not be 15%), and more likely to label symptoms as a recognized quickly for intervention. Research behavior-related, bipolar, or mood disorder NOS has identified symptom dimensions that are simi- (Payne, 2014). Clinician education in differen- lar to those found in previous studies of predomi- tial symptom expression is essential for accurate nantly European and European Americans, diagnosis and treatment for depression in African including contamination/washing, symmetry/ Americans. perfectionism, doubts about harm/checking, sexual obsessions/reassurance, and aggression/mental compulsions. Generalized Anxiety and Panic African Americans with OCD were more Disorder likely to endorse not being understood clearly as a primary concern when compared to European Anxiety disorders, such as generalized anxiety Americans (Williams, Elstein, Buckner, Abelson, disorder (GAD) and panic disorder (PD), are less & Himle, 2012). This finding, along with more frequently diagnosed in African Americans, commonly endorsed concerns related to contami- although those with a diagnosis may have a lon- nation, potentially indicates that specific cultural ger duration of illness than European Americans. experiences and values may influence the presen- This underdiagnosis can be impacted by African tation of obsessive compulsive symptoms in American clients’ discomfort with disclosing African Americans. For example, experiences cognitive or emotional symptoms of anxiety due with disenfranchisement as a result of ethnic and to cultural mistrust and stigma towards mental racial discrimination may further perpetuate anx- health (Hunter & Schmidt, 2010). However, iety about not being heard or understood, while much like MDD, African Americans are more prejudiced assumptions about the cleanliness of likely to disclose physical symptoms of anxiety African Americans may further perpetuate con- (Hunter & Schmidt, 2010), particularly since car- tamination concerns (Williams, Debreaux, & diovascular illness, which some anxiety symp- Jahn, 2016). Additionally, research has shown a toms may mirror (Sung et al., 2018), is a prevalent connection between experiences of discrimina- concern within this community. Misinterpretation tion and severity of symptoms (Williams et al., of anxiety symptoms as cardiac illness prevents 2017). clients from receiving effective treatment, and African Americans’ distress can worsen when experiencing physical anxiety symptoms, as they Post-traumatic Stress Disorder may feel more vulnerable to poor cardiac outcomes, leading to more anxiety about their health Although African Americans may have a lower (Gordon & Teachman, 2008). Like many other prevalence of anxiety disorders, the National disorders, GAD has been connected to experi- Survey of American Life (NSAL) found that 9 Behavioral Health Service Delivery with African Americans 115

African Americans have a higher prevalence rate anorexia was lower for African American adults for PTSD, at 9.1% versus 6.8% in non-Hispanic (14.9 years) in comparison to a similar national Whites (Himle et al., 2009). PTSD may be more study with primarily European Americans, whose disabling for African Americans who experience age of onset was during late adolescence significantly more impairment at work and in (18.9 years). It appears that when African carrying out everyday activities (Himle et al., Americans do have anorexia, the age of onset is 2009). African Americans have high rates of lower and the course of the disorder is longer trauma exposure. Half have reported experienc- (Franko, 2007). ing someone close to them die unexpectedly, These lower rates of anorexia are thought to almost half have been victims of assaultive vio- be due to African American culture’s reduced lence, and nearly one in five has been in a life- emphasis on thinness operating as a protective threatening car accident. Males have frequently factor, as African American men may prefer been exposed to war-related combat and over a women with curvier figures. Nonetheless, third have been mugged. Among African African American women can still feel social American women, over one in six have been pressure to be thin. Lifetime prevalence rates badly beaten by a spouse, over one in six have found for bulimia in African Americans is 1.5% been raped, and one in five has experienced for adults, which is slightly higher than the another kind of sexual assault (Ching, Williams, national average of 1.0%. The average age of & Taylor, 2018). onset is 19 years, which is the same as the gen- Experiences with racial discrimination are eral population. Successful prevention efforts another reason African Americans experience should not focus on body image or disordered higher rates of PTSD, also termed racial trauma eating directly, but rather address the thinness (Butts, 2002). Common examples include harass- ideal indirectly, or focus on promoting healthy ment by law enforcement and mistreatment in the eating in lieu of eliminating unhealthy habits workplace (Williams, Metzger, Leins, & DeLapp, (Franko, 2007). 2018). Racial discrimination is a stressor that Binge eating was the most prevalent eating induces distress, frustration, and anxiety, disorder among African Americans, with a life- adversely affects mental and physical health. It time prevalence of 1.7%, although 5.1% exhib- often leads to increases in dysfunctional coping ited some problems with binge eating whether or strategies, such as substance use, isolation, and not they met criteria for a disorder (Franko, risky sexual activity. 2007). Among all demographics, African American women have the highest obesity rates. African American women struggle more to lose Eating Disorders and Obesity weight after pregnancy. They also eat fewer fruits, vegetables, and whole grains, and con- In examining eating disorders in African sume more added sugars, sodium, and calories Americans, NSAL found that anorexia was a rare from fat when compared to women of other occurrence; in fact, not a single woman met crite- groups. Further, African American women ria for anorexia in the previous 12 months, and engage in less leisure-time physical activity com- there were no present or lifetime reports of pared with African American men and people of anorexia in Caribbean adults in the study. These other racial and ethnic groups. Hair care practices findings indicate that African Americans are at are a common barrier to physical activity among lower risk of anorexia than their European African American women, as getting hair wet American counterparts, and Caribbean Americans through sweating or swimming may necessitate are at an even lower risk. However, among those extra hours for grooming (Agyemang & Powell- who did have a diagnosis, the age of onset for Wiley, 2013). 116 M. T. Williams et al.

Attention-Deficit Hyperactivity terpretation of symptoms, such as externalized Disorder behavioral problems, on the part of parents and clinicians may also contribute to increased diag- African American children are also impacted by nosis delay (Burkett et al., 2015; Mandell et al., disparities in diagnosis. Attention-deficit hyper- 2007). Unfortunately, clinicians’ cultural biases activity disorder (ADHD) is less commonly diag- may lend to the perception that African American nosed among African American children (Liang children’s externalizing behaviors are more et al., 2016), with one study finding them to be important to address, leading to an increase in 69% less likely than European American children the misdiagnosis of ASD as conduct-related dis- to receive the diagnosis (Morgan, Staff, orders (Liang et al., 2016). Research on autism Hillemeier, Farkas, & Maczuga, 2013). African in African Americans is sorely lacking. American children with an ADHD diagnosis or symptoms are also less likely to use medications to manage symptoms (Morgan et al., 2013), even Conduct Disorder when controlling for factors such as symptom severity, comorbid symptoms (i.e., conduct and Conduct disorder (CD) is more often diagnosed oppositional defiant disorder), and household in African American populations, particularly in income (Coker et al., 2016). Being male and low-income areas, adolescents, and city residents exhibiting problematic externalizing behaviors (Mizock & Harkins, 2011). Although this overdi- increase the odds that an African American child agnosis is influenced by a number of factors, will receive an ADHD diagnosis (Morgan et al., there has been insufficient research on the impact 2013), meaning that girls with ADHD and those of historical inequity and biased sociocultural with primarily inattentiveness are at risk for a attitudes on overdiagnosis (Atkins-Loria et al., missed diagnosis. 2015). African Americans, particularly males are more likely to be inequitably punished by teachers and targeted by law enforcement, leading to Autism Spectrum Disorder higher rates of disciplinary actions, delinquency, and legal problems. Additionally, in impover- African American children with autism spec- ished neighborhoods, which are disproportion- trum disorder (ASD) are more likely to have a ately African American, youth may join gangs for delay in diagnosis than European American chil- protection. These type of problems are all part of dren, with an average delay of about 1.5 years. the diagnostic criteria for conduct disorder, lead- These children were misdiagnosed three-fold ing to inflated prevalence rates among African over European American children and were American youth. more likely to have an initial diagnosis of a con- Across race, a diagnosis of CD can impact duct-related or adjustment disorder (Mandell, youths’ legal and clinical outcomes, including Ittenbach, Levy, & Pinto-Martin, 2007). This more severe sentencing, moving youth cases to delay in identification can be devastating for adult courts, and lower provider expectations for long-term outcomes, as early intervention is crit- clinical improvement and law-abiding behavior, ical for optimal language development and which may lead to lower quality treatment reduced symptom severity long term. African (Atkins-Loria et al., 2015; Rockett, Murrie, American parents of autistic children who worry Boccaccini, & Deleon, 2007). Outcomes are par- about healthcare discrimination may encourage ticularly disturbing in regards to racial disparities their children to become more independent, and in CD. Even when symptoms and crimes are thus appear higher functioning than they actually comparable, African Americans are diagnosed are (Burkett, Morris, Manning-Courtney, with CD more often than European Americans, Anthony, & Shambley-Ebron, 2015). The misin- are incarcerated at higher rates, and are more 9 Behavioral Health Service Delivery with African Americans 117 likely to have criminal activity accredited to per- significant implications on the quality of care sonality as opposed to situational factors (Bridges patients receive; patients with public funded & Steen, 1998; Mizock & Harkins, 2011). insurance receive a lesser quality of care than Clinicians may contribute to this disparity when those with private insurance (Smedley et al., utilizing risk assessments allowing for subjective 2003). Coverage for substance use and mental bias, evaluating African American youth with health services, if included at all, is substan- less regard for environmental factors, using prev- tially lower than coverage for other medical ill- alence rates among African Americans to inform nesses and is significantly more expensive. a CD diagnosis, and/or having reduced cultural Despite the passage of the Affordable Care Act competence (Mizock & Harkins, 2011). These in 2010, which greatly expanded insurance cov- disparities in incarceration and quality clinical erage, barriers remain in both access to and care can prevent African Americans from experi- quality of care; this includes the availability of encing equal juvenile justice outcomes, taking culturally informed services. There are not more years of freedom from African American enough mental health clinicians of color to meet youth with a CD diagnosis through increased the needs of the whole African American com- prison time, due to lower quality assessments and munity due to disparities in education and legal bias. opportunities. African Americans only make up 2% of psychiatrists (Duffy et al., 2004), 6.5% of psychologists, but 23.5% of social workers Barriers to Treatment (U.S. Bureau of Labor Statistics, 2018). Thus, culturally competent care is even more crucial Treatment Issues to improving utilization of services and effectiveness of treatment for African American com- Mental health disparities, or unfair differences in munities. Services lacking cultural sensitivity the quality of health care according to race and often perpetuate negative stereotypes which can ethnicity, are common even when controlling fac- further stigmatize the act of seeking treatment tors related to accessibility, such as insurance sta- (Thompson, Bazile, & Akbar, 2004). This can tus and income (Smedley, Stith, & Nelson, 2003). make it difficult to connect with mental health Studies show that African Americans often uti- providers and contribute to the notion that men- lize general health services when seeking treat- tal health care is not relevant to African ment for mental health concerns, resulting in Americans. inadequate depth and quality of treatment Cultural mistrust decreases help-seeking (Neighbors, Caldwell, & Williams, 2007; Primm, behaviors and lowers participation in treatment. 2006). African Americans may consider a pri- Within the African American community, cul- mary care provider (PCP) more ideal than a men- tural mistrust stems from several sources and tal health specialist, since psychotherapy is often includes a widespread lack of cultural compe- considered to be something “for White people.” tency among clinicians and therapists (HHS, Seeking behavioral treatment of any kind is 2001; Griffith, Johnson, Zhang, Neighbors, & highly stigmatized, and Black culture is generally Jackson, 2011; Williams, Duque, Chapman, socialized against it. Wetterneck, & DeLapp, 2017). Other factors that African Americans who overcome stigma have cultivated mistrust of mental health services and are able to seek treatment are left to navi- among African Americans are historical and cur- gate an expensive and fragmented medical sys- rent medical and research abuses (Suite et al., tem with numerous administrative obstacles. 2007). Mistrust relates to not only events such as Consequentially, many end up unable to access the Tuskegee Syphilis Study but even more recent the mental health care they need. The insurance publicized abuses such as the Johns Hopkins factor is a vital one as it has been shown to have Lead Paint Study and Guatemala STD Trials 118 M. T. Williams et al.

(Gamble, 1997; HHS, 2001; Spriggs, 2004), loss of control. These fears may be exacerbated along with abuses against Black people that by the connection to stigmatizing notions about might periodically appear on the evening news. drugs of abuse and stereotypes about Black peo- This cultural knowledge along with ongoing con- ple as addicts. Further, taking medication may firmation of provider biases in the form of less feel at odds with African American cultural val- respect and microaggressions perpetuate the cul- ues surrounding persevering through difficulties, tural mistrust and stigma associated with higher and thus be considered “taking the easy way out.” African Americans attrition rates. There is an important role for the therapist in educating African Americans with accurate information about medication for mental health condi- Treatment Engagement tions. It can be helpful to conceptualize mental disorders as biological conditions, which can be Treatment engagement has been noted as a prob- helped with biological interventions, such as lem in the delivery of mental health care for medication. Further, therapists can talk to clients African Americans (Waldrop & de Arellano, candidly about the pros and cons of therapy with 2004). There are several factors that contribute to or without concomitant medication. It should low engagement, including perceptions of therapy also be emphasized that for most conditions, such as being irrelevant to real-life problems, stigma as depression and anxiety, therapy is likely to be and shame, family stressors, and lack of aware- more effective. ness of available resources (Williams, Beckmann- Clinician biases are a major factor in medica- Mendez, & Turkheimer, 2013; Williams, tion mismanagement for African American Domanico, Marques, Leblanc, & Turkheimer, patients. Prescribers tend to underestimate depres- 2012). Treatment adherence is one area in which sion and anxiety in African Americans and fail to culture, race, and ethnicity have been clearly dem- properly medicate for these conditions. Further, onstrated as relevant to treatment success assessments of dangerousness and potential for (Waldrop & de Arellano, 2004). The apparent rel- violence are overestimated for African Americans, evance of treatment approach to problems experi- in accordance with violent and criminal stereo- enced (such as discrimination, limited access to types. Black patients are then given higher doses resources, or the overlap of treatment content with of antipsychotic medications when compared to the client’s own experiences) will improve client White patients with the same severity of illness engagement and adherence. Cultural relevance (Woods et al., 2003). As a result Africans are less has been shown to make a difference with the likely to receive needed SSRIs and more likely to retention of information and knowledge (Wilson be prescribed too much or completely unneces- & Cottone, 2013), so a culturally informed sary antipsychotic medications. approach to treatment is essential not only for the This is compounded by the fact that African sake of avoiding attrition but also for ensuring that Americans, like many other ethnic minorities, the work done in therapy is retained by the client metabolize antidepressants and antipsychotic and put into practice. medications more slowly than Whites and may be more sensitive to the medications. This higher sensitivity is manifested in a faster and higher Medication Issues rate of response and more severe side effects, including delirium when treated with doses com- African Americans may avoid care due to nega- monly used for White patients (Muñoz & tive or inaccurate health beliefs about psychiatric Hilgenberg, 2006). Thus, African Americans may medications (Schnittker, 2003). Common fears exhibit poorer medication compliance, which about medication are that it will change one’s then may be misinterpreted as resistance to treat- personality, cause dependence, and/or lead to ment. This may make the whole process of help 9 Behavioral Health Service Delivery with African Americans 119 seeking for mental health care aversive for not feel optimistic (Thompson et al., 2013). patients who may be reluctant to return for Collaborative therapeutic relationships that needed assistance. If medications are in fact war- remain authentic and honest can convey to cli- ranted, this is an important place for the therapist ents that their needs are being heard and are con- to intervene. This may include reaching out to the sidered important (HHS, 2014). Engaging in client’s current prescriber to provide input on open communication allows space for client’s diagnoses or helping the client locate someone viewpoints and concerns to be acknowledged who is culturally competent in working with potentially increasing their likelihood of remain- African Americans. In such cases, a personal ing in care (Carpenter-Song, 2010). connection to the prescriber may be important for It is also vital that, in return, clinicians are success. open with African American clients when discussing treatment approach, timelines, and goals, as transparency surrounding intentions for treat- Facilitators to Treatment ment can reduce cultural mistrust and provide additional opportunities for clinician–client col- Providers’ active effort to incorporating facilita- laboration. Transparency concerning treatment tors in behavioral health treatment utilization and goals and planning can encourage collaboration retention for African Americans can promote and shared ownership of the treatment direction, higher quality access and care. These efforts may but it can also encourage treatment retention for be multifaceted and the opportunity to improve African American clients by clarifying the practi- services can begin with clinicians’ and clients’ cal benefits of treatment. African Americans may initial encounters. African Americans who report be more likely to end behavioral health interven- optimistic expectations for treatment are increas- tions prematurely if there is no clear connection ingly satisfied with later treatment outcomes. between treatment strategies and their impact on These positive expectations can be cultivated client’s concerns (Carpenter-Song, 2010). Thus, when clients know of a loved one who has bene- communicating clear and definable mechanisms fited from treatment, if they themselves have had by which a given treatment can impact real-world affirmative past therapeutic experiences, or if the change in client’s symptoms and their personal clinician instills a sense of optimism (Thompson circumstances can demonstrate to African et al., 2013). When implemented into practice, American clients the efficacy and value of thera- the following treatment facilitators may not only peutic intervention. The benefits of therapy benefit African American clients directly but may should not only stress its personal value but also also have a ripple effect, promoting optimistic potential improvements in one’s ability function expectations in others who interact with your in the role of parent, spouse, caregiver, employee, client. and friend. Leveraging the importance of one’s mental health for the collective good can help defuse the notion that treatment is strictly a per- Provider and Treatment Transparency sonal, individualistic, and potentially self- indulgent endeavor. Unfortunately, not all clients who access behavioral health services will have positive expectations of treatment. African American clients, or Emphasizing Biological Factors caregivers of child clients, may hold negative or for Families ambivalent beliefs about the efficacy of therapeutic interventions; however, clinicians can African American clients may benefit from a num- facilitate a sense of understanding and transpar- ber of culturally tailored emphases in treatment. ency by acknowledging early on that clients may As with positive expectations potentially having a 120 M. T. Williams et al. feedback loop effect, unfortunately, this may be Considering income limitations and the insur- true for negative family interactions in African ance barriers previously mentioned, providing Americans with mental illness. African Americans quality care at an affordable price can increase with OCD report greater occurrences of negative African Americans access and retention in behav- family interactions, which may be a leading risk ioral health services. Even among African factor to the development and maintenance of Americans who can afford care, the perceptions OCD and/or OCD behaviors may contribute to that treatment might not be valuable may deter poorer interactions, as family members may expe- willingness to initiate or remain in therapy. rience stress and perceive symptoms as unwar- Implementing low-cost contingency manage- ranted (Himle et al., 2017). As alluded to ment practices for African Americans with higher previously, increasing an emphasis on the biologi- levels of distress and symptom severity can cal factors which contribute to disorders through increase treatment retention, without signifi- psychoeducation may help destigmatize and cantly impacting institutions or providers reduce tensions within families, by countering the finances (Bride & Humble, 2008; Post, Cruz, & dominant cultural belief that client self-discipline Harman, 2006). can eliminate symptomatology. The conviction Emphasizing resilience and positive changes that individual responsibility and self-control are can also facilitate treatment retention. Stigma vital in overcoming behavioral and mood concerns surrounding mental health disorders can be can undermine African Americans’ reliance on increasingly salient for African American cli- behavioral health services. The biological basis of ents and can impact feelings of self-worth disorders can help counter to this cultural concern (Kawaii-Bogue et al., 2017). Reducing clinical (Carpenter-Song, 2010), so it remains important to jargon and terms that may amplify the focus on continue fostering a collaborative relationship and deficits by addressing disordered symptoms as not force this paradigm shift; however, incorporat- “concerns” or “challenges” can help reduce this ing a biological emphasis may also provide the stigma (Carpenter-Song, 2010). Focusing on foundation for more understanding among family clients’ strengths and ability to overcome can members and legitimize the utilization of thera- encourage an empowering narrative (HHS, peutic interventions. Incorporating psychoeduca- 2014), providing African American clients a tion on biological factors in psychopathology can sense of resiliency that may be consistent with also illustrate the link between mental and physi- cultural narratives surrounding racial struggle cal health, which may be particularly salient con- and triumph. Group treatment for African sidering African Americans likelihood of Americans may be well positioned to amplify experiencing somatic symptoms and worry per- this effect, as community members can build on taining to poor health outcomes (Gordon & their sense of resiliency through a collective Teachman, 2008). narrative of empowerment (e.g., Carlson, Endlsey, Motley, Shawahin, & Williams, 2018).

Sociocultural Considerations Treatment Environment Knowledge and utilization of African Americans’ shared cultural values and experiences can facili- Individuals are part of a larger social context tate therapeutic growth and alliance when inte- which contributes to perception of comfortability grated into behavioral health service delivery. and familiarity—significant aspects of the treat- Economic hardship is particularly salient in ment environment. There are many facets to cre- African American communities, with average ating a comfortable space, and these differ by household incomes more than $20,000 dollars culture. In terms of creating ambiance, like less than their European American counterparts everyone else, African American clients want to (Kawaii-Bogue, Williams, & MacNear, 2017). be comfortable in the environment. Clinicians 9 Behavioral Health Service Delivery with African Americans 121 should always consider the décor of the counsel- lives with extended family and the home too ing facility. Color schemes, music, African noisy or distracting). In this case, the therapist American-based magazines, Afrocentric cultural would have been better off taking more time to office artwork can all be critically important in understand the problem, rather than jumping to a making clients feel comfortable and welcome solution informed by negative stereotypes. Thus, (Williams et al., 2013). Also consider shifting it is critical that therapists learn to actively chal- context and setting as needed. Therapy can come lenge their biases in this regard. in many forms besides conversation or sitting in an office. Therapists might consider relocating therapy to other settings that allow the client to Building Trust and Rapport access healing with familiar venues and enjoy- able activities (Parham, 2002). Such locations Authenticity is an important virtue in African include local churches, community or recre- American culture. Due to dealing with a lifetime ational centers, schools, or favored restaurants. of covert racism, African Americans are socially Considering the importance of the communal programmed to look for subtle signs that European environment in many African American commu- Americans are trustworthy, and this may be par- nities, a therapist providing treatment within those ticularly relevant in healthcare. Even other people communities may result in greater treatment ini- of color who are part of the greater healthcare tiation and engagement. Through partnership and establishment may not be automatically trusted, community engagement on the part of the therapist, as they may be viewed as a tool of the White local hubs for galvanization and solidarity can establishment. The more genuine and authentic also be an avenue for connecting community the therapist is, the better the therapeutic rapport. members with more formalized medical treat- If a provider comes across as quiet and distant, ment. Further, when providing therapy in a com- African American clients may assume the thera- munal setting, therapists would likely build a pist is hiding something important from them or favorable reputation both with the client and the treating them differently due to their race. community members which can provide the ther- Although many therapeutic approaches empha- apist with organic access to the content and func- size interpersonal distance, a style that includes tionality of said culture and community. Therapists openness, warmth, transparency, and mutual vul- should take time to visit African American com- nerability will be more palatable for African munities, patronize local businesses, and build a American clients. Consider that therapists are positive presence in the community. asking clients who have a history of being oppressed and betrayed to share personal infor- Increasing Clinician Efficacy mation with a complete stranger. Further, as many Before working with African Americans, clini- African Americans are coming to therapy often as cians must be willing to examine their own (mis) a last resort to deal with mental health concerns, perceptions and correct any stereotypical beliefs. they are often looking for practical solutions to Pervasive negative stereotypes about African their problems and may feel like they are in crisis American people include notions such as lazy, (whether or not they openly admit to being in such poor, unintelligent, criminal, and sexually preda- a state). tory/deviant. If therapists believe these stereo- As a result, certain types of therapies may be types, even to a small extent, it will become better suited to African Americans than others. evident in the course of conversations and thera- We strongly recommend behavioral therapy sup- peutic interventions. For example, if a student is plemented with functional analytic psychother- struggling in school, the therapist may suggest a apy (FAP) for African American clients (e.g., tutor (working based on assumptions of decreased Graham-LoPresti, Gautier, Sorenson, & Hayes- aptitude) when in fact a quiet study area may Skelton, 2017; Miller, Williams, Wetterneck, actually be what is needed (perhaps the student Kanter, & Tsai, 2015), as FAP focuses on cultivating 122 M. T. Williams et al. an authentic therapeutic connection. Cognitive come. The traditional tools you have learned as therapy may also be helpful, but given the high a therapist will continue to be useful for potential of inappropriate cognitive restructuring African Americans. However, European by therapists unfamiliar with the lived experience American counselors and therapists working of racism, cognitive therapy should only be with African American clients need to bring a attempted by those clinicians with a very deep special sensitivity and competence to a thera- understanding of how racism functions in peutic relationship. Work with African American culture. Certainly, non-CBT modali- Americans should be culturally specific to ties can be helpful, but the opaque nature of psy- facilitate the process; in other words it will be choanalysis may fuel greater suspicion in African helpful to understand cultural values and the American clients, and other non-directive Black experience in America (Parham, 2002). approaches may seem pointless and frustrating to Therapists should be attentive to the behaviors clients with emergent needs for help. they use to build the therapeutic alliance, espe- Cultural sensitivity can be enhanced by cially if they have utilized one set of behaviors broaching differences early in treatment. Unlike for a long time, these may not be as effective with African American therapists, European American African American clients, who may be approach- therapists have more discomfort discussing race ing the situation with caution. The therapist in cross-racial dyads (Knox, Burkard, Johnson, should openly acknowledge and validate African Suzuki, & Ponterotto, 2003). White therapists American distrust if it is present. Avoid pushing may have difficulty discussing race because it too hard, seeming interrogative, or premature may not be something they talk about frequently, interpretations; building trust takes time. but sweeping it under the rug can invalidate cli- When greeting African Americans, the follow- ents’ experiences as a person of color. Raising the ing guidelines can be helpful (Lee & Roberts, issue of race early in the therapeutic relationship 2008). Shaking hands is common practice for conveys cultural sensitivity and may address cli- both men and women. Be formal at the beginning ents’ concerns about a racially different coun- and do not call an African American by their first selor. For example, a White therapist could say, name unless the person invites you to do so, as “Sometimes clients feel uncomfortable working this could be insulting, particularly for older cli- with a counselor of a different race; how is this ents. Using formal titles, such as “Ms.” or for you?” “Doctor” is a form of respect, and respect is a In counseling situations the role of the clini- critical component of the African American value cian is guided by a theoretical orientation as system. You can show also respect by saying well as the beliefs about how and why clients something like, “It’s really nice to meet you.” In will experience some relief and resolution terms of personal space, African Americans are (e.g., psychoanalysis, interpersonal, CBT). As comfortable with closer and less formal dis- you enter the therapeutic relationship, thera- tances, and may only be 1–2 feet away, but you pists are advised to promote themselves as must establish trust before assuming familiarity vehicle for change rather than the agent of or closeness. Eye contact can be very direct, change, to help clients maintain a sense of con- especially when speaking but may be indirect trol. Further, African Americans prefer for you when listening. When building rapport, you can “tell it like it is.” It is important that at the out- start with anything you would normally talk set of therapy, you as a therapist explain what about with other long-established American cul- you are doing and how it will work. If the pro- tural groups, such as the weather, entertainment, cess is mysterious it may generate suspicion sports, or local news. Men may not always be and mistrust. Therapists are expected to use an comfortable talking about themselves right away, array of skills and techniques that are intended so therapists should not be put off if they seem to bring about some desired therapeutic out- guarded initially. Although African Americans 9 Behavioral Health Service Delivery with African Americans 123 tend to prefer very direct verbal communication, • Self: In contrast to Eurocentric psychological non-verbal communication is very important and models of the self that are fragmented (e.g., id, can convey more meaning than in almost any ego, superego; actions, behaviors, and cogni- other culture, as gestures can be more enthusias- tions), the Afrocentric self is viewed as a uni- tic than most non-African Americans are accus- tary, holistic entity, which is a reflection of tomed to. Finally, the African American culture one’s inner spirit (i.e., spiritness made has a long history of storytelling, so feel free tell evident). stories to engage clients. • Feelings: In contrast the notion that maturity and professionalism require silencing one’s emotions, an Afrocentric approach values Afrocentric Values emotion. Emotions are legitimate, should be expressed, reflect one’s vitality, and commu- Afrocentric values can help facilitate the treat- nicate aliveness. However, many African ment process. Afrocentric values should not be Americans have learned to stifle their emo- confused with the African American images seen tions as a survival mechanism (i.e., “John in the media and commercial music, which Henryism,” and the “cool pose”). emphasize materialism, commercialized hip-hop, • Survival: In contrast to competitive notions drug culture, stereotypes, and urban clothing. It is such as “survival of the fittest,” the Afrocentric easy to confuse cultural values and stereotypes. worldview values the collective. This is Remember, pathological stereotypes are over- embodied in the African saying, “‘I am generalized or false ideas about a group that is because we are, and because we are, I am.” advanced to justify or explain inequities. Cultural • Language: In contrast to written history, oral values, on the other hand, are actual differences traditions pass down community history, in the beliefs, attitudes, and practices of a particu- allowing the living to feel connected to elders lar group. These represent average differences, of past. Also, responses are valued after a and so obviously, not everyone in a given cultural statement is made as a recognition of under- group identifies with all of their group’s cultural standing (i.e., call-response). values. Even so, most people in that cultural • Time: In contrast to the Eurocentric emphasis group will understand and appreciate the differ- on precision, time is not measured through ences, even if they do not adhere to them. standard units, but by major life events and Afrocentrism is rooted in idealized African thus can be cyclical across the lifespan as values and can be an excellent vehicle for pro- events are re-experienced (i.e., births, mar- moting healing in African American clients. In an riages). Time is not treated as currency but an Afrocentric worldview, spirituality is a means of opportunity for shared experiences. self-definition and a primary coping resource. • Universe: In contrast to the notion that our Understanding the importance of spirituality surroundings are to be controlled, the universe within the African American community is cru- is viewed as harmonious. Even within the cial, as the church is a resource for religious, per- hierarchy, from God to plants, all beings are sonal, family, and political support. Therapists connected. will be viewed as more credible in this commu- • Death: Death is not seen as an end, but phase nity if they are competent in religious and spiri- of life. Elders are among the most respected tual issues. Although not all clinicians are members and ascend the hierarchy as “living religious, the goal is to accurately understand dead,” gaining immortality through oral individuals within their cultural context in order history. to best deliver culturally informed interventions. • Worth: A person’s value is not how much The Afrocentric worldview has been high- wealth they amassed during their lives, but lighted by Parham (2002) as rooted in the follow- rather value is measured by the contributions ing understanding: they have made to the community. 124 M. T. Williams et al.

African American values include optimism, mission of the client, the therapist can reach out humor, creativity, resilience, perseverance, to the religious healer to describe the client’s uniqueness, self-expression, healthy skepticism, problem and their own model for the therapeutic being genuine, assertive, and honest. Additional treatment approach. If the religious healer is strengths include the ability to adapt to changing supportive, then that will go a long way toward societal and economic contexts, a strong work helping the client feel motivated to fully partici- orientation, and drive to “make ends meet.” pate in therapy. It can also be helpful for the reli- Appreciating and incorporating these values into gious healer to know what practices, if any, are therapeutic work can be a powerful means of counterproductive for the client’s progress progress and healing. (Williams, Duque, et al., 2017). Other than mainstream religions, there are many traditional practices used as ways to con- Respect Religious and Traditional nect spiritually, medicinally, and even psychi- Healing Practices cally. Many immigrants have introduced their approaches to health and well-being into Many types of specialists may be involved in Western culture, and so clients may be adher- some facet of a client’s mental health care. These ents of alternative traditional medicine. Such may include family doctors, psychiatrists, social practices may include herbal medicine, Voodoo, workers, clergy, and other traditional healers. Santeria, and New Age therapies. Therapists Therapists need to be aware of all the resources should be prepared to discuss the role of the tra- clients access for support to ensure harmonious ditional healer with their clients. Even if the and effective treatment while respecting the cli- therapist feels completely certain the traditional ent’s values and culture. approach is not helpful, it is important to show In the face of what may appear to be worries respect for these systems. Indigenous, cultural, of a spiritual nature (which may be present and traditional healing practices are time-hon- within anxiety, depression, OCD, and psycho- ored methods that many have historically been sis), a religious healer may seem like the most used to alleviate both physical and psychologi- appropriate person to provide help. Churches cal problems – sometimes for thousands of built on African and African American heritage years. Although examples of traditional treat- have historically served as a source for support ment that have caused harm are frequently cited, and social services, such as alcohol and drug many find these approaches central to their abuse recovery, health screenings, counseling, well-being (Pouchly, 2012). education, and other treatment-oriented pro- It is also important to understand that religion gramming (Blank, Mahmood, Fox, & Guterbock, does not cause mental disorders. Even if the cli- 2002). As such, African Americans with mental ent’s disorder has religious themes therapists health concerns may enlist pastors, elders, should be careful not to blame a client’s religion priests, prophets, and other religious healers for for symptoms. If the therapist mistakenly thinks prayer, advice, and even “casting out of demons.” that religion is causing the problem, this may However, sometimes therapists are not in agree- result in efforts control or suppress the client’s ment that these type of healers are actually help- beliefs to facilitate treatment. This is sure to ful, and there may even be a concern that undermine trust and empathy, leading to conflict religious approaches are making symptoms and drop out. Therefore, the best approach is to worse. Given a conflict between a therapist and work respectfully within the confines of the cli- clergy, the client will usually side with clergy ent’s religious beliefs and traditions to ultimately and abandon the therapist. Thus, it is better to facilitate treatment engagement. In fact, it is collaborate with the religious healer rather than much more effective to recruit the client’s reli- force the client to make a choice. With the per- gious values in service of treatment than to try to 9 Behavioral Health Service Delivery with African Americans 125 suppress them. In most cases, the mental health as such, there is no single solution. However, problem has gotten in the way of carrying out many interventions have been presented which proper religious duties (i.e., prayer, attendance at can work together to change the experience of services, fellowship, important ceremonies) mental health treatment for not just African rather than improving religious life. The therapist Americans, but people of all ethnic groups. can underscore that successful treatment will Although the behavioral healthcare system is facilitate fuller participation in religious priori- fragmented, there are still new treatment ties and improve the client’s connection with approaches being developed, tested, and imple- their spirituality (Williams, 2017). mented on a regular basis. So long as these treatments and services aim to accommodate and include the needs and cultural sensitivities of Check-ins and Review of Progress African Americans and other groups, there is great promise for those in need of behavioral It is important to periodically share information health interventions. with clients about how well they are progressing toward their goals. Periodic check-ins further promote change through review and renewal of Resources commitment to the process. Clinicians may know what a client is experiencing in the There are a number of resources that can help moment, but more importantly, therapists need inform work with African Americans. Therapists to know what a client has found facilitative or can make use these and other resources as a not helpful about particular aspects of therapy. means to reduce mental health disparities and Clients should be reminded throughout the treat- help facilitate the critical development of holistic ment process that successful interventions rarely and culturally sensitive behavioral health ser- occur as a single moment in time but rather in a vices for African Americans, and other vulnera- series of successive steps, each of which brings a ble populations. client closer to their goals. Clients should be taught to anticipate setbacks, as work will • Black Psychiatrists of America (www.bpainc- include positive and negative outcomes. This psych.org). may help in dealing with frustration in unplanned • The National Association of Black Social outcomes. One good gauge of progress is to Workers (www.nabsw.org). examine whether the individual has been able to • The Association of Black Psychologists achieve a sense of balance and harmony in life. (http://www.abpsi.org/). Finally, clients should be reminded that although • The Black Mental Health Alliance (www. they are in the moment, they are always in a state blackmentalhealth.com). of becoming more self-actualized. (Parham, • The Community Healing Network (https:// 2002). In other words, although there may be www.communityhealingnet.org/). clear goals for therapy, growth is a journey not a • The HHS Office of Minority Health (https:// destination. www.minorityhealth.hhs.gov/).

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Gordon C. Nagayama Hall and Ellen R. Huang

People of Asian ancestry are the largest ethnic ery and effectiveness of behavioral health group worldwide and the fastest growing ethnic services. group in the USA. The Asian American popula- In this chapter, we begin by discussing how tion grew from 11.9 million in 2000 to 20.4 mil- federal behavioral health policies have failed to lion in 2015 and are the largest group of new benefit Asian Americans. We then discuss the immigrants to the USA since 2010 (Lopez, Ruiz, persistent underutilization of behavioral health & Patten, 2017). At 5.7% of the US population services by Asian Americans. We follow with a (U.S. Census Bureau, 2017), Asian Americans review of efforts to make behavioral health ser- may be perceived by some to be a small group. vices more culturally relevant to Asian Americans. However, the number of Asian Americans in the Cultural relevance includes the use of alternative USA exceeds the combined populations of the services outside of behavioral health services set- country’s three largest cities (New York, Los tings. We conclude with a discussion of future Angeles, Chicago). This number also exceeds the directions for research and behavioral health ser- number of Americans who suffer from major vice delivery. depression (Hall & Yee, 2012). Yet, Asian Americans are a relatively invisible group in behavioral health service delivery. Federal Behavioral Health Policies The invisibility of Asian Americans is associated with stereotypes about them (Huang & Hall, Behavioral health services became widely acces- in press). Model minority stereotypes promote sible in the USA during the 1960s with the pas- the perception that Asian Americans are self- sage of the Community Mental Health Centers sufficient and do not need help. Perpetual for- (CMHC) Act in 1963 (Hall & Yee, 2012). This eigner stereotypes make Asian Americans feel coincided with a large increase in the Asian unimportant because they are not perceived to be American population; the Immigration Act of Americans. Because of this invisibility, many 1965 removed many restrictions on Asian immi- perceive Asian Americans as a group that does gration (Deaux, 2006). Unfortunately, the Reagan not merit special attention. Yet, there are issues administration repealed the CMHC Act in 1981 unique to Asian Americans that affect the deliv- (Stockdill, 2005). As a result, many community mental health centers were closed. However, the G. C. Nagayama Hall (*) · E. R. Huang existing community mental health centers were Department of Psychology, University of Oregon, not adequately meeting the needs of Asian Eugene, OR, USA Americans. Asian Americans have utilized e-mail: [email protected]

© Springer Nature Switzerland AG 2020 131 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_10 132 G. C. Nagayama Hall and E. R. Huang behavioral health services at lower rates than any Neuroscience can assist in determining the rele- other ethnic group over the past four decades vance and effectiveness of behavioral health (SAMSHA, 2015; S. Sue, 1977). More on Asian interventions and in personalizing treatments. Americans’ underutilization of behavioral health This will be discussed later in this chapter. services will be discussed later in this chapter. However, the tools of neuroscience have yet to be Since the 1980s, behavioral health care policy harnessed for this purpose (Gabrieli, Ghosh, & in the USA shifted from a focus on access to care, Whitfield-Gabrieli, 2015). to improving the quality of care (Kiesler, 1992). This policy shift was the impetus for the evidence- based treatments (EBTs) movement (Rosner, Underutilization of Treatment 2005). However, EBTs were designed by and for European Americans, not people of color (Hall, The federal policies described above have failed 2001). The randomized clinical trials to establish to impact one of the most enduring health dispar- the validity of new EBTs did not include Asian ities—underutilization of behavioral health ser- Americans or other groups of color. vices by Asian Americans. Stanley Sue first The 1990s became the “Decade of the Brain” documented this in 1977 in a landmark study of under the George H. W. Bush administration over 13,000 clients in 17 community mental (NIMH, 1999). The biological basis of mental health centers in the Seattle, WA area. Asian disorders was prioritized in research funding. Americans were underrepresented in service uti- The 2000s and 2010s have continued to be lization relative to their representation in the decades of the brain (Miller, 2010). National local population more than any other ethnic Institute of Mental Health (NIMH) Director group. Four decades later, this pattern has not Thomas Insel (2003) proclaimed that mental ill- changed. National data indicate that in every nesses are “brain illnesses.” Although the focus adult age group, Asian Americans are the ethnic on the brain has provided innovative ways to group that is least likely to use behavioral health learn more about behavior, this focus on the brain services (SAMHSA, 2015). has shifted public attention and resources away Why does this pattern of underutilization from behavioral health services. exist? Perhaps Asian Americans are more men- Members of the NIMH National Advisory tally healthy than other groups. There is evidence Mental Health Council recently estimated that from national epidemiological surveys that Asian 85% of the NIMH budget is devoted to basic Americans have lower rates of psychopathology research, such as neuroimaging (Lewis-than other ethnic groups (Miranda, McGuire, Fernández, Rotheram-Borus, et al., 2016). Only Williams, & Wang, 2008). These lower rates of 15% is devoted to clinical research, including psychopathology might be reflected in lower work on behavioral health interventions. The rates of behavioral health service use. However, basic research that is funded typically takes many the measures of psychopathology utilized in years until it is translated into behavioral health these epidemiological surveys did not assess interventions that address public health needs culture-specific forms of psychopathology. For (Lewis-Fernández et al., 2016). In some cases, example, somatic rather than emotional expres- basic research does not ever lead to behavioral sion of distress is common among people of health interventions. Similar to the research on Asian ancestry (Ryder et al., 2008). EBTs, Asian Americans are rarely represented in In addition, psychopathology prevalence dif- basic research. Thus, basic research may divert fers between generation groups (i.e., immigrant attention and funding from clinical research that generation vs. children of immigrants [second directly addresses the behavioral health needs of generation] vs. third-generation). Thus, nativity diverse communities. impacts mental health. Second generation Neuroscience research, however, is not neces- (US-born) Asian Americans have higher lifetime sarily at odds with behavioral health services. psychopathology rates than immigrant Asian 10 Asian Americans 133

Americans (Hong, Walton, Tamaki, & Sabin, Asian Americans may be less likely than 2014). These include higher rates of anxiety dis- European Americans to seek behavioral health orders, depression, and substance use disorders, services because they perceive them as less ben- than immigrant Asian Americans (Hong et al., eficial than European Americans do (Kim & 2014). Gender also impacts mental health. Zane, 2016). Asian Americans may also view US-born Asian American women have signifi- mainstream behavioral health services that cantly higher rates of any anxiety disorder, require self-disclosure as foreign, as it is not depression, and substance use disorders than common in Asian cultures to self-disclose immigrant Asian American women (Hong et al., (J. Chen & Danish, 2010). In contrast, problem- 2014). This immigrant health paradox suggests solving for many Asian Americans may involve that living in the USA may have iatrogenic indirect coping, such as accepting a situation and effects. enduring a problem while being nonreactive When Asian Americans experience psycho- (Hall, Hong, Zane, & Meyer, 2011). Moreover, logical distress, behavioral health service utiliza- the focus on interdependence in many Asian tion disparities exist. In an epidemiological study, American cultures is largely absent from main- 54% of European Americans who had a diagnos- stream behavioral health services. Thus, for able mental disorder sought behavioral health many Asian Americans, existing behavioral services (Wang et al., 2005). In contrast, a com- health services are not viewed as culturally parable epidemiological study indicated that only relevant. 28% of Asian Americans with diagnosable mental disorders sought behavioral health services (Meyer, Zane, Cho, & Takeuchi, 2009). An addi- Efforts to Make Behavioral Health tional 16% of Asian Americans with diagnosable Services Culturally Relevant mental disorders sought help in primary care ser- for Asian Americans vices and 11% used alternative services, such as healers or religious advisors. Behavioral health The underutilization of behavioral health ser- services are the treatment of choice for European vices by Asian Americans and other groups of Americans with mental disorders. However, color has prompted researchers and clinicians to Asian Americans are nearly equally likely to seek explore how to make these services culturally rel- help for mental disorders from other providers evant. Some efforts have focused on the thera- (Meyer et al., 2009). A review of studies indicates pists and others have focused on therapy. that being able to recognize a mental disorder is Therapist foci have included ethnic matching of insufficient to promote behavioral health service therapists and clients, and therapist cultural com- utilization among Asian Americans (Na, Ryder, petence. The major focus in therapy has been on & Kirmayer, 2016). culturally adapted interventions. Given that nearly three out of four Asian American adults were born in Asia (U.S. Census Bureau, 2017), it might be expected that accul- Ethnic Matching turation is associated with behavioral health service use. Mainstream behavioral health services Seeing a therapist that looks like oneself may be a would be expected to be more appealing to proxy for cultural competence. A client may acculturated Asian Americans. However, in a assume that a therapist of the same ethnicity meta-analysis, acculturation was weakly associ- shares knowledge about their cultural back- ated with behavioral health service use among ground. Such assumptions may be less likely Asian Americans (Smith & Trimble, 2016). when there is not an ethnic match between client Thus, regardless of acculturation level, few and therapist. Of course, ethnic similarity is not Asian Americans use behavioral health equivalent to cultural similarity. A therapist and services. client of the same ethnicity may differ on many 134 G. C. Nagayama Hall and E. R. Huang characteristics, including acculturation, education, Association [APA], 2017a). Thus, Asian and socioeconomic status. Nevertheless, for many Americans are somewhat underrepresented in clients, knowing that therapists of their own eth- psychology relative to their representation of nicity are available may attract them to seek and 5.7% of the US population (U.S. Census Bureau, remain in treatment. 2016). The difference between the representation Following his work in Seattle, Stanley Sue, of Asian Americans in psychology and in the Fujino, Hu, Takeuchi, and Zane (1991) investi- USA may seem insignificant. However, Asian gated the effects of culturally responsive behav- Americans are the fastest growing ethnic group ioral health services in Los Angeles County. in the USA. Thus, more Asian American psy- Cultural responsiveness involved ethnic and lan- chologists who are multilingual need to be trained guage matching of therapists and clients. Ethnic to adequately address current and future public matching was associated with participating in health needs. more treatment sessions for clients of all ethnici- There may be pipeline barriers to increasing ties. However, for Asian Americans and Mexican the representation of Asian Americans in psychol- Americans, ethnic match was associated with ogy. From 2007 to 2008, only 7% of first-time more treatment sessions only for those whose doctoral students were Asian Americans (APA, primary language was not English. Thus, lan- 2009). Now, 10 years later, the percentage of guage match accounted for the effects of ethnic Asian Americans in graduate school for psychol- match. ogy only rose 1%, to 8% (APA, 2017b). And at A meta-analysis indicates that in subsequent graduation, about 5% of clinical psychology doc- studies, the effects of ethnic match on treatment torates awarded went to Asian Americans (APA, retention have shown a moderate effect for Asian 2010). The supply of Asian Americans who are Americans and weaker effects for other ethnic potential psychologists may be even more limited groups (Smith & Trimble, 2016). Similar to the at the beginning of the pipeline. In a sample of results of the S. Sue et al. (1991) study, language eighth and tenth grade Asian Americans in the match accounted for the effects of ethnic match. Midwest, less than 3% chose psychologist as a Thus, having a therapist who speaks the same career goal (Howard et al., 2011). The most com- language is particularly important for Asian mon goals were artist and fashion designer among Americans. Asian American females and computer careers Although ethnic and language matching may among Asian American males. Asian Americans prevent therapy attrition for Asian Americans, the aspired to careers with prestige and high salaries. effects of such matching on treatment outcomes Asian American youth may not perceive a career (e.g., symptom reduction) are weak (Cabral & as a psychologist as conferring either. Smith, 2011). Thus, the primary benefits of eth- Families may influence the attractiveness of nic matching may be when clients first enter psychology as a career. Family support for choos- treatment. Nevertheless, these initial benefits ing a science-oriented or a helping career influ- may be important in increasing Asian Americans’ enced whether Asian American college students utilization of behavioral health services. would choose these careers (Hui & Lent, 2018). What is the availability of Asian American However, there is a limited number of Asian therapists? Some may assume that Asian Americans who use or are familiar with behav- Americans are overrepresented in psychology ioral health services. Thus, support for a child’s similar to their overrepresentation in other sci- career as a psychologist may be limited in many ence fields (National Science Foundation, 2013). Asian American families. Greater education However, such an assumption may be based on about psychology as a career, such as high school the model minority stereotype. Recent data indi- psychology classes, may be needed for psychol- cate that Asian Americans are 4% of the US psy- ogy to be considered a viable career for many chology workforce (American Psychological Asian Americans. 10 Asian Americans 135

Cultural Competence cultural competence. Similar to the findings for ethnic/language match, a meta-analysis indicates Ethnic matching is not available in many behav- that clients’ perceptions of therapists’ cultural ioral health service settings. How can the 96% of competence are associated with longer participa- psychologists who are not Asian American effec- tion in therapy (Smith & Trimble, 2016). In addi- tively treat Asian American clients? One approach tion, common factors, such as perceived therapist is cultural competence. warmth and empathy, are associated with thera- Derald Wing Sue, Arredondo, and McDavis pists’ perceived cultural competence (1992) defined cultural competence as having (Constantine, 2007; Fuertes et al., 2006). three components: (a) awareness of how one’s However, similar to the findings for ethnic/lan- cultural values and biases impact the client; (b) guage match, the effects of clients’ perceptions knowledge of the client’s culture; and (c) skills in of therapists’ cultural competence on treatment providing culturally relevant treatment. This outcomes are minimal (Smith & Trimble, 2016). model is the basis of professional guidelines for cultural competence. The goal of therapist cultural competence is to produce positive outcomes Cultural Adaptations for clients (S. Sue, Zane, Hall, & Berger, 2009). Indeed, even European American therapists, as Although ethnic/language matching and therapist long as their ethnic minority clients perceived cultural competence have weak effects on treat- them to be culturally competent, had a strong ment outcomes, cultural adaptations of interven- working alliance with their clients (Constantine, tions have been shown in recent meta-analyses to 2007; Fuertes et al., 2006) and were effective have moderate effects on reducing psychopathol- with ethnic minority clients (Hinton et al., 2004, ogy (Hall, Ibaraki, Huang, Marti, & Stice, 2016; 2005). Smith & Trimble, 2016). A cultural adaptation In a review of the cultural competence litera- has been defined as “the systematic modification ture, Chu, Leino, Pflum, and Sue (2016) con- of an evidence-based treatment or intervention tended that cultural competence is effective protocol to consider language, culture, and con- because it considers clients’ psychosocial context in such a way that it is compatible with the texts, adapts the therapeutic approach to the cli- client’s cultural patterns, meanings, and values” ent, and focuses on therapist qualities. Clients’ (Bernal, Jiménez-Chafey, & Domenech social contexts include social and environmental Rodríguez, 2009, p. 362). Unlike ethnic match- factors such as discrimination, poverty, immigra- ing and cultural competence, cultural adaptations tion, and inadequate educational resources. focus on the therapy rather than the therapist. Social contexts also include cultural norms. The Cultural adaptation models have been devel- therapeutic approach may include therapist–cli- oped for Asian American populations. Leong ent ethnic or language matching. It also may and Lee’s (2006) cultural accommodation model involve incorporating cultural concepts, such as is a top-down adaptation of existing behavioral interdependence. Therapist qualities include health interventions and involves three steps. empathy, self-awareness, and the ability to The first is the identification of the cultural limi- empower clients. Thus, cultural competence goes tations of theories assumed to be universal. For beyond simply matching clients and therapists on example, EBTs focus on the individual and typi- a demographic basis. cally do not address interdependence. The sec- What are the effects of cultural competence on ond step is the identification of such therapy? Therapists’ perceptions of their own culture-specific psychopathology, such as soma- cultural competence are not associated with their tization. The third step is to develop a culturally clients’ experiences in therapy (Smith & Trimble, accommodated intervention and to evaluate if it 2016). More informative than therapists’ percep- has incremental validity over the unaccommo- tions are clients’ perceptions of their therapists’ dated model. 136 G. C. Nagayama Hall and E. R. Huang

Hwang (2006) also proposed a cultural adap- may describe physical symptoms instead of psy- tation framework for Asian Americans. Principles chological symptoms when talking about her that guide the framework include general guide- depression to her family, so as not to scare them. lines for adapting cognitive-behavioral therapy The therapists’ response to their clients’ indirect (CBT) to meet the needs of Chinese American communication was to become more direct in clients, strengthening the client–therapist rela- their communication with their clients, such as tionship, and understanding Chinese notions of directly asking about their client’s problems (Hall self and mental illness. The framework incorpo- et al., 2019). rates top-down adaptation, as well as bottom-up Cultural adaptations extend the reach of development of culture-specific interventions. In evidence-based interventions. However, similar developing culture-specific interventions, com- to EBTs, culturally adapted interventions tend to munity input is solicited from clinicians, experts, be broadly applied. As Hall et al. (2019) found, community members, and clients. However, therapists in the USA and Japan apply cultural many clinicians may not follow the guidance of adaptations involving interdependence to clients conceptual frameworks, such as Leong and Lee’s of Asian ancestry. However, interdependence (2006) or Hwang’s (2006) models, for cultural may not apply to all people of Asian ancestry. adaptation in clinical practice (Smith & Trimble, Asian Americans may vary on interdependence 2016). based on their acculturation level and ethnic Hall et al. (2019) investigated how practicing identity. Highly acculturated Asian Americans therapists in the USA and Japan culturally adapt with limited ethnic identity may not benefit from CBT with clients of Asian ancestry. Unlike the a culturally adapted intervention. In this case, independent cultures in which CBT originated, unadapted interventions may be beneficial (Hall interdependence is emphasized both among & Ibaraki, 2016). Asian Americans and in Japan. Semi-structured, As discussed above, the personal and cultural open-ended interviews revealed that therapists in relevance of behavioral health services may influ- both countries addressed interdependent concep- ence their effectiveness for Asian Americans. tualizations of the self. The intrapersonal Social neuroscience may offer a promising approach of CBT was adapted to address social method to address how self-relevant an interven- roles and norms in family, school, and work set- tion is to the individual client. Neuroscience evi- tings. For example, a Japanese therapist described dence suggests that the self-relevance of an how a new member of a sports team needed to intervention may predict its effectiveness. A adjust to her role on the team: study on the relative effectiveness of smoking The skills needed in our culture are something dif- cessation campaigns found that the medial pre- ferent from the U.S. We call it the senpai-kohai frontal cortical (mPFC) response predicted the relationship. Senpai is the older member and kohai effectiveness of these campaigns (Falk, Berkman, is the younger member. The kohai, the younger & Lieberman, 2012). mPFC activity is associated member, has to show respect for the older member in a very strict way like their teachers or older with self-related processing, which may indicate people. that the most effective campaigns were self- relevant. Interestingly, self-reported relevance of Another cultural adaptation that Hall et al. (2019) the campaigns did not predict effectiveness. identified was therapists addressing clients’ indi- Thus, neuromarkers offer a promising way to rect communication. For example, clients’ seek- match effective treatment approaches, such as ing therapy may tacitly communicate that they culturally adapted interventions, with particular are experiencing distress but they may not clients. directly discuss the distress. Indirect communica- For many Asian Americans, conventional tion may serve to maintain group harmony in evidence-based cognitive-behavioral interven- interdependent cultural contexts (Hall et al., tions that focus on the self may not be perceived 2011). For example, a depressed Chinese mother as personally or culturally relevant. These 10 Asian Americans 137 approaches focus on individual cognitions and analysis indicate that Asian cultural values, emotions, which may not be as informative about including emotional self-control, conformity to health for Asian Americans as they are for social norms, and collectivism, are associated European Americans, as discussed above. In con- with a lower likelihood of having positive atti- trast, many Asian Americans may want to address tudes toward seeking psychological help (Sun more pragmatic concerns in therapy, such as fam- et al., 2016). Thus, in order to meet many Asian ily, school, and work issues. For example, Ibaraki Americans’ behavioral health needs, services and Hall (2014) found that addressing academic may need to be delivered in contexts besides tra- concerns in counseling with Asian American col- ditional ones, such as primary care or ethnic lege students was associated with participating in community service agencies. a significantly greater number of counseling ses- Primary care settings may not carry the stigma sions than when academic concerns were not of mental health care settings. Moreover, as psy- addressed. chological distress is commonly manifested A cognitive-behavioral treatment approach somatically for people of Asian ancestry (Ryder that may have personal and cultural relevance for et al., 2008), seeking help in these settings for Asian Americans is Social Problem-Solving distress manifested as a physical health disorder Therapy (SPST; Nezu & Nezu, 2016). SPST (e.g., sleep problems) may carry less stigma than focuses on stressful problems in the real world. seeking help for a psychological disorder (e.g., Social problem-solving is the process by which depression). Common reported symptoms people attempt to cope with these stressful prob- include sleep problems (i.e., sleeping too little or lems by altering the problem situation, their reac- too much) and pain. Asian Americans who view tion to the problem situation, or both. The distress as biologically based may be more likely problem-focus of SPST has been found to be than those who view distress as interpersonally more self-relevant that a focus on emotions for based to seek help from behavioral health provid- Chinese American elderly adults, whose culture ers (Na et al., 2016). emphasizes emotional moderation (Chu, Huynh, A medical setting might also provide an & Areán, 2012). We are currently evaluating the opportunity for mental health literacy education personal and cultural relevance of SPST based on (Na et al., 2016). Mental health problems could self-report and neuroimaging with Asian be presented as a disease, similar to physical ill- American adults (Huang, Hall, & Berkman, ness. Similar to physical illness symptoms, men- 2019). Personal and cultural relevance of a tal illness symptoms warrant professional help. behavioral health intervention could potentially For example, sleep interventions administered in predict the effectiveness of the intervention. a primary care setting do not carry the stigma of mental health interventions. These interventions address a somatic problem, which may make Alternative Services sleep interventions particularly relevant for many Asian Americans. Moreover, some sleep disor- Regardless of the effectiveness of efforts to make ders, including short sleep duration and sleep dis- behavioral health services culturally relevant for ordered breathing, are prominent among Asian Asian Americans, many Asian Americans will Americans (Chen et al., 2015). Sleep interven- never benefit from these services because they tions not only improve sleep duration and quality, will not seek them. As discussed above, the com- but have been demonstrated to reduce depression bined percentages of Asian Americans with men- (Hasler, Buysse, & Germain, 2016). Asian tal disorders who seek help in primary care Americans who would not otherwise seek behav- settings (16%) or alternative service settings ioral health services might be attracted to sleep (11%) is nearly equal to the 28% who seek help interventions that address both somatic and psy- in behavioral health service settings (Meyer chological symptoms of distress. Successful et al., 2009). Moreover, the results of a meta- sleep interventions might also make Asian 138 G. C. Nagayama Hall and E. R. Huang

Americans open to other interventions to reduce Over 30 years later, this distal focus continues psychological distress. and may explain why the reach of behavioral Alternative care settings might also offer health services to Asian Americans remains lim- opportunities to provide behavioral health ser- ited. Asian Americans are a diverse group in vices. Movement-based approaches may be terms of national and cultural backgrounds. appealing to some Asian Americans because of However, these groups have been combined in their Asian philosophical roots. For example, most research. The broad category of Asian lishi is a traditional form of a Chinese movement American is a distal variable. A much more fine- system. Lishi promotes breathing, balance, coor- grained approach is necessary. dination, and alignment. The movements and There are six Asian American ethnic groups stances involve images relevant to Asian cultures that number one million or larger (U.S. Census that were named after animals and objects that Bureau, 2016). Most of the psychology literature are commonly found in traditional Chinese cul- on Asian Americans focuses on people with tures. Results of preliminary work by Nolan Zane Chinese and Korean ancestry (Kiang, Cheah, and colleagues indicate that Southeast Asians Huynh, Wang, & Yoshikawa, 2016). Americans who practiced lishi exhibited improved psycho- of Chinese ancestry are the largest Asian logical well-being and physical balance relative American ethnic group at 4.9 million (U.S. Census to a control group. Lishi is culturally relevant and Bureau, 2016). However, Asian Indian Americans its group format encourages social interaction number 4.1 million, Filipinx Americans number and ethnic identity, which have been shown to be 3.9 million, and Vietnamese Americans number protective factors against depression (Rivas- two million, Korean Americans number 1.8 mil- Drake et al., 2014). lion, and Japanese Americans number 1.4 mil- Unfortunately, the research on alternative ser- lion. Thus, there is a need for more research on vices for Asian Americans is virtually non- the heterogeneity within the broad category of existent. Nevertheless, it is important to evaluate Asian Americans. the effectiveness of alternative services relative to As discussed previously, behavioral health conventional behavioral health services. If the services, including those that are culturally two types of services are on par with respect to adapted, tend to be broadly applied. However, reducing mental disorders, perhaps greater atten- culturally adapted interventions based on East tion and resources should be devoted to alterna- Asian cultures (e.g., Hwang, 2006; Leong & Lee, tive services as an approach to improving Asian 2006) are not necessarily applicable to other Americans’ mental health. Asian cultures. Although the quest for cultural relevance is complex and costly, it is critical to reduce health disparities for Asian Americans, Future Directions who utilize behavioral health services at a lower rate than any other ethnic group in the USA Efforts to extend the reach of behavioral health (SAMHSA, 2015). services to Asian Americans and other people of A variable that is somewhat more proximal to color have largely failed. In a classic conceptual- behavioral health services outcomes than ethnic- ization, S. Sue and Zane (1987) contended that ity is collectivism or interdependence. As dis- distal variables, such as client ethnicity and ther- cussed previously, collectivism has been found to apy techniques, are less influential on behavioral be associated with a lower likelihood of having health service outcomes for people of color than positive attitudes toward seeking psychological proximal variables that are more culturally rele- help (Sun et al., 2016). Interdependence has been vant to particular individuals. Sue and Zane identified as a critical issue in cultural adapta- (1987) observed that most strategies to improve tions of psychotherapy with people of color, and the effectiveness of behavioral health services therapists may adapt behavioral health services with people of color focused on distal variables. to address interdependence (Hall, 2001; Hall 10 Asian Americans 139 et al., 2019). However, the effects of incorporat- ated with internalizing disorders, it may be a pro- ing interdependence in psychotherapy have not tective factor against externalizing disorders. In a been evaluated. Moreover, interdependence is a national sample of college-aged men, concern broad and relatively distal construct that varies about loss of face was a deterrent against sexually according to cultural context. aggressive behavior 1 year later for Asian Within and across ethnic groups, Asian American men but not for European American Americans vary on acculturation. As discussed men (Hall, DeGarmo, Eap, Teten, & Sue, 2006). previously, acculturation was weakly associated Thus, concern about the impact of one’s behavior with behavioral health service use among Asian on the group may be a deterrent against aggres- Americans (Smith & Trimble, 2016). This may sive behavior in interdependent cultural be because of psychometric limitations of accul- contexts. turation measures. Acculturation also is relatively Future research on Asian Americans could distal to behavior. address how face concerns influence usage and A construct more proximal to behavior for impact of behavioral health services. The effect many Asian Americans is face (Leong, Byrne, of mental health literacy interventions to reduce Hardin, Zhang, & Chong, 2017). Face involves the stigma and loss of face associated with seek- one’s prestige and position in society. Loss of ing help could be evaluated (Choi & Miller, face is a loss of prestige and status through viola- 2014). Addressing face concerns in therapy could tions of collective norms. For example, failing to also be examined as a method of increasing self- fulfill the obligations of one’s role as a family disclosure (Zane & Ku, 2014). In addition, vari- member (e.g., be a good student) causes face loss ability among Asian American ethnic groups in for the individual, as well as the whole family. A the effects of face concerns could be evaluated. person concerned about face loss is vigilant about For example, Chinese Americans have been the impact of their behavior on others. Concern found to be more concerned about loss of face about saving face facilitates the functioning of than are other Asian American groups (Braje & the group among Asians and other interdepen- Hall, 2016). dent groups (Zane & Yeh, 2002). The fact that Asian Americans are the ethnic Loss of face is more pronounced among Asian group that is least likely to use behavioral health Americans than among European Americans services suggests that they are the group that war- (Leong et al., 2017). It is also more pronounced rants the most attention. This is one of the most among less acculturated Asian Americans. It is persistent public health disparities. Yet, Asian positively associated with depression and social Americans have been overlooked in behavioral avoidance. Moreover, face concern has been health policies (Hall & Yee, 2012). Asian found to inhibit self-disclosure in therapy (Zane Americans will need to be prioritized in behav- & Ku, 2014). Concern about loss of face may be ioral health policies, research, and services if less adaptive in independent contexts in which mental health disparities are to be reduced. face concerns tend not to guide behavior. Otherwise, the behavioral health services dispari- Recent research suggests that loss of face is ties of the past four decades will continue. not associated with psychopathology among Asian Americans per se. The association of concerns about loss of face and depression and anxi- References ety were mediated by an avoidant coping style (Braje & Hall, 2016). However, concern about American Psychological Association. (2009). 2009: loss of face coupled with a direct problem- Graduate study in psychology. 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Lisa A. Duke and Hikianaliʻa Foster

Please note the authors are aware that some historical E lauhoe mai nā wa a; i ke kā, i ka facts that can be found in the literature may be inaccurate. ʻ They also acknowledge the many different perspectives hoe; i ka hoe, i ke kā; pae aku i ka from historical events. They have made attempts to find ʻāina the most accurate information and exclude all biases, but humbly ask for forgiveness of anything that is uninten- Translation: Everybody paddle the canoes tionally misrepresented. together; bail and paddle, paddle and bail; and L. A. Duke (*) the shore will be reached. Waianae Coast Comprehensive Health Center, Figurative Translation: If everybody pitches Waianae, HI, USA in, the work is quickly done. e-mail: [email protected] When paddling the canoe, everyone has a H. Foster special role to fulfill and is vital to the success University of Hawaii at Manoa, Honolulu, HI, USA

© Springer Nature Switzerland AG 2020 143 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_11 144 L. A. Duke and H. Foster of the voyage. The “stroker” occupies the first Part I Background History seat and seats 1 and 2 have the role of ensuring the rhythm and pace of the paddle strokes. Seats Pacific Islanders are well known for their knowl- 2 and 3 call the changes when the paddlers edge and history of voyaging. To begin this chap- change sides of the canoe. Seats 3 and 4 are ter and discussion of how to effectively work with often called the power seats and are for the Pacific Islanders, we must first discuss who the strongest paddlers. Seat 4 has the additional term “Pacific Islanders” refers to. Figure 11.1 responsibility of bailing out the water when nec- above shows the map of Oceania. The islands essary. Seat 5 is responsible for having the within the narrower definition of the Pacific knowledge of steering to assist the steersperson Islanders include those within Polynesia, when necessary. They must also keep the ama Micronesia, and Melanesia. The broader defini- (outer float). Seat 6 is the steersperson, or the tion of the Pacific Islanders includes those within captain of the canoe. They are responsible for Polynesia, Micronesia, and Melanesia, as well as motivating the crew and setting up the canoe for adjacent countries in this map (Philippines and the best course and catching the swells. If every- China) and other Asian cultures that have also had body works together the work will be done major migrations to the Pacific Islands (Japanese, quickly. Embodied within this metaphor/story Korean, and Filipino). The broadly defined Asian are the traditional cultural values of Pacific American and Native Hawaiian/Pacific Islander Islanders that continue to guide their way of liv- community is one of the fastest growing racial/ ing. Metaphors like this one are commonly ethnic groups (Hoeffel, Rastogi, Kim, & Shahid, infused in treatment to remind people of the 2012). In the State of Hawaii, more than 2/3 of the importance of their individual role within the population consider themselves as non-white success of the group. according to US Census Bureau (2012).

Fig. 11.1 Map of Oceania 11 Behavioral Health Service Delivery with Pacific Islanders 145

Within the narrower definition of Pacific Islanders, many of the island cultures share similar beliefs, values, and customs. The Pacific Islands also share many characteristics as they are small and remote. The islands were previously self-sufficient but presently depend on outside resources. The largest group of Pacific Islanders are the indigenous people in the islands of Hawaiʻi, the Native Hawaiians, “kanaka maoli,” meaning real or true person (Blaisdell, 1989; Mau et al., 2010). The Hawaiian Islands are within the Polynesia group of Oceania. Early Polynesians were voyagers and used stars, ocean current, wind, and birds as navigational tools. The decision to navigate to find new lands was believed to be due to increas- Fig. 11.2 Traditional Hawaiian Society (Kameeleihiwa, ing populations. All Polynesian societies were 1992) similar in that they had three main classes of people, this includes the royal class (aliʻi), was Hāloa-naka, who was still-born and buried. It priests (kahuna), and the commoners was from his burial site that Hawaiʻi’s main staple (makaʻāinana). Above all people were their plant came about, the kalo or taro. Their second akua, or Gods and spirits, which they believe are child was Hāloa, who became the first Aliʻi Nui of present in all natural things. There were many Hawaiʻi (Kameeleihiwa, 1992). It is from this ceremonies and rituals to please the Gods. With genealogical story that Hawaiians had high value the societal classes in Polynesia, genealogy was and respect for land as it is their ancestor and of great importance in knowing where one stood older sibling who showed that the land will care within a society. The importance of family and for its people if the people care for the land. With extended family is important throughout this, villages or clans were strategically set up so Polynesia and most often traced through the all people had access to all resources from moun- paternal side. tain to ocean. Family played an important role for The Hawaiian Islands were no different from the Hawaiian people who could trace their lineage its Polynesian counterparts. Figure 11.2 shows a through the paternal or maternal line. Kinship more detailed version of the traditional Hawaiian rather than race were early defining factors that society. This triangle shows the top as being most helped to develop the multi-racial climate of sacred or kapu and working its way downwards. Hawaiʻi today (McDermott & Andrade, 2011). The Mōʻī was the high chief who worked closely Hawaiians like many other Pacific Islanders with Aliʻi Nui (Political Council) and Kahuna Nui believed that all things have mana or power. There (religious advisors). The Aliʻi Nui and Kahuna was mana in knowledge, living things, items, and Nui had people below them who would then work so on. Knowing one’s genealogy held a great with the makaʻāinana (commoners). Hawaiian amount of mana and shaped the Traditional history and genealogy shows that the Hawaiian Hawaiian society. Some of the most common Islands themselves are direct descendants of the populations currently represented in the islands of Gods and came long before humans. The legends Hawaiʻi are Samoan, Fijians, Tongans, Chuukese, tell the story of the islands being born from and New Zealanders. Wākea, our sky-father, and Papahānaumoku, our Within this narrower definition of Pacific earth-mother. They then had their first human off- Islanders, not only do its members share similar spring, Hoʻohōkūkalani, who later had children values, cultures, and customs, but they also face with Wākea. The first of their children together many of the same challenges. This may be related 146 L. A. Duke and H. Foster to microgenetics or exposure to European cul- could destroy social and spiritual relationships as ture. Rates of heart disease and diabetes are much can be shown in Table 11.1 (McCubbin & higher among groups of Pacific Islanders than of Marsella, 2009). Negative actions could allow those endorsing Asian descent (Juarez, Davis, spiritual forces to enter in their lives, so ritualistic Brady, & Chung, 2012). Similarly, Pacific behaviors, such as those in Table 11.2, are required Islanders have higher rates of poverty, substance with Native Hawaiian traditional healing arts abuse, and over-representation in jails and pris- (McCubbin & Marsella, 2009). Traditional ons compared to Asian Americans. Native Hawaiian medicinal practices, or Lāʻau Lapaʻau, Hawaiians have the highest incidence of morbid- are practiced by Hawaiian practitioners. The tra- ity and mortality, the highest age-adjusted mor- ditional practices are handed down in families or tality, and the highest rate of health disparities of to other people who show promise. This tradition any ethnic group in Hawaiʻi (Anderson et al., of passing on knowledge is something that many 2006; Braun, Look, & Tsark, 1995). Native Pacific Island cultures have in common. Hawaiians may also have even higher rates of substance abuse, arrests, and incarceration of all Table 11.1 Prosocial vs. antisocial behavior (adapted ethnic groups in Hawaiʻi (Kanaʻiaupuni, Malone, from McCubbin & Marsella, 2009) & Ishibashi, 2005). Consequently, the risks of Prosocial behavior Antisocial behavior combining the many ethnicities that identify as • Humility and modesty • Hate (inaina) Pacific Islander/Asian American may result in a (ha‘aha‘a) loss of significant findings and identification of • Politeness and • Jealousy (lili) meaningful differences. kindness (‘olu‘olu) • Helpfulness (kōkua) • Rudeness (ho‘okano) • Acceptance, • Being nosy (nīele) hospitality, and love Historical Culture of Hawaiʻi (aloha) • Respect (hō‘ihi) • Bearing a grudge Archaeological evidence suggests that the inhab- (ho‘omauhala) • Caring (m lama) • Bragging (ha‘anui) itants of Hawaiʻi began between 200 and 600 A.D. ā (Graves & Addison, 1995). There were likely two • Showing off (ho‘oi‘o) • Breaking promises waves of migration from other areas of Polynesia. (hua ‘ōlelo) Early settlers may have been forced back into • Speaking bitter deeper valleys. The chiefs (ali’i), changed fre- thoughts (waha ‘awa) quently, typically through negotiation or battles • Stealing (‘aihue) and it was their duty to make sure their people’s • Fighting (hakakā) needs were met. See Handy and Pukui (1972) for • Anger (huhū) a more comprehensive written account of Ancient Hawaiian culture. As previously explained, Table 11.2 Native Hawaiian traditional healing (adapted Hawaiians did not own the land but rather worked from McCubbin & Marsella, 2009) with the land as if it were a living family member Native Hawaiian traditional healing (Kameeleihiwa, 1992). The Hawaiians believed • Spiritual healing (lā‘au kāhea) in many different gods and goddesses and built • Medicinal healing (lā‘au lapa‘au) heiau to worship them. Ancient Hawaiians had • Massage (lomilomi) four major gods, Kāne, Kanaloa, Kū, and Lono, • Conflict resolution (ho‘oponopono) although there is some disagreement over their • Apology (mihi) descriptions. The gods and goddesses took on • Dream interpretation (moe ‘uhane) many physical forms (kinolau) like plants and • Clairvoyance (hihi‘o) animals that became sacred (kapu) (Kameeleihiwa, • Prayer (pule ho‘onoa) 1992). The Hawaiians also had many words to • Cleanse with sprinkling salt water (pī kai) describe prosocial behavior and those things that • Purification sea bath (kapu kai) 11 Behavioral Health Service Delivery with Pacific Islanders 147

Colonization “Apology Bill” (US Public Law 103–150) of 1993 by President Clinton (Cummings, 2002). After European’s first contact with the Hawaiian This acknowledged the illegal overthrow of the Islands in 1778 with Captain Cook and 1820 with Kingdom of Hawaiʻi and apologized to Native European missionaries, the population of Native Hawaiians on behalf of the people of the USA Hawaiians changed from approximately 700,000 (Lander & Puhipau, 1993). (although estimates vary widely) to 40,000 in Annexation resulted in a changing economy 1893 (McCubbin & Marsella, 2009). Colonizers with an influx of services both good and bad. The brought with them livestock, clothing, plants, locals, who were self-sufficient people and metal weaponry, and diseases. Reasons underly- worked to maintain their community with no ing the dramatic decrease in the population were income or titles to lands, were forced into a new the introduction of illness and new weaponry. economic system that they were not prepared for. Indigenous species populations also decreased as Foreigners began to buy lands and take owner- they could not survive the new invasive species. ship of places that were free for all people to use Early accounts of Europeans and missionaries and the natives suffered greatly. As an example of described Native Hawaiians as “savages” and how westernization has affected the lifestyle of “inferior” to Europeans (McCubbin & Marsella, many Native Hawaiians, consider how the tradi- 2009). Many other Pacific Islanders have dealt tional diet, which was low in fat and high in com- with similar if not worse effects of colonization plex carbohydrates, has changed to a typically and the early negative beliefs of Europeans. western diet, high in fat and low in complex carbohydrates (Blaisdell, 1993, 1996). Studies in Hawaiʻi and other islands have suggested that a The Overthrow of Hawaiʻi return to traditional diets, focused on staples, such as taro, breadfruit, and sweet potato, could There are some additional influences that have help lower serum cholesterol, blood sugar levels, dramatically impacted culture in Hawaiʻi. At the and other obesity related conditions. Other time when Hawaiʻi, under the reign of Queen Pacific Islands have also suffered from colonial- Liliʻuokalani, was illegally overthrown by the ism by Westerners. Many of the surrounding USA in 1893, the locals had no claims to the land islands were used to test nuclear bombs, which and many were against annexation. Queen caused a loss of natural resources and made for Liliʻuokalani was overthrown in a time where she unhealthy living conditions. Micronesia is one wanted to do justice for her people and change example, where nuclear testing occurred. The the constitution, known as the Bayonet USA has tried to help by providing canned meat Constitution, that her brother and ruler before and fish and access to medical care; however, the her, King Kalākaua, was forced to sign. The Micronesian people face similar health and social Bayonet Constitution, written by Lorrin Thurston, disparities as Hawaiians and their lands will gave white foreigners power over the Hawaiian likely never be the same. legislature and cabinet (Kameeleihiwa, 1995). A With annexation many of the traditional group of Americans, who became known as the Hawaiian language and practices were banned. In Provisional Government of Hawaiʻi, undermined the 1970s, when Hawaiian practices were no lon- the queen to gain Hawaiʻi as a territory of the ger illegal, there was a resurgence in Hawaiian USA. President Cleveland later considered the culture termed the Hawaiian Renaissance, involv- overthrow of Hawaiʻi “an act of war” and felt that ing a movement towards improving spirit and “a substantial wrong has been done” that they health by utilizing cultural practices. Some “should endeavor to repair” (Lander & Puhipau, examples of this resurgence included develop- 1993) with the provisional government not ask- ment of a Hawaiian immersion educational pro- ing the people of Hawaii a formal vote for annex- gram in 1984–1985, as a way for the Hawaiian ation. A formal apology was later made with the language and culture to remain alive. The 148 L. A. Duke and H. Foster

Hawaiian Cultural Influences in Education evalu- term “melting pot” is often used to describe the ated culture-based education strategies and edu- theory that each cultural identity would “assimi- cational outcomes of students linked with positive late” to shed their previous identities and to become impact on emotional and cognitive engagement, American. In Hawaiʻi and most other Pacific community connectedness, positive self-concept, Islands, they are thought of as a “stew” when it and participation in cultural activities (Carlton comes to cultural interactions where each culture is et al., 2011). Several other types of programs and not expected to give up their ethnic identities to partnerships have been formed since this forge into one, but rather, there is a horizontal and Hawaiian Renaissance to incorporate cultural vertical appreciation of the cultural and racial iden- values within all aspects of life including health tities of others (McDermott & Andrade, 2011); care with positive outcomes. The Native Hawaiian however, some may reject both terms. Pacific partnership formed in 2005 was designed to pro- Islanders are often more accepting of other cultures vide culturally responsive substance abuse and being that they were victims of colonialism and mental health treatment. In the health care aspect understand how that can negatively affect a per- of Hawaiʻi, the University of Hawaiʻi John A son’s culture and identity. For example, many of Burns School of Medicine has partnered with the cultural traditions, holidays, and foods from multiple community sites to implement delivery other countries are still represented among many of cutting-edge services to rural and hard to reach people residing in Hawaiʻi. Holidays such as New populations. Since the Hawaiian Renaissance, Years, Chinese New Year, Boys Day and Girls Day, there have been continual efforts of Native Prince Kūhiō Day, and King Kamehameha Day Hawaiians to further help the growth of the are among the many that are celebrated in Hawaiʻi. Hawaiian culture. The story of the overthrow of Foods from many different ethnic backgrounds can the Hawaiian islands is one that is well known be easily found within the islands as well. You can throughout the world, but the experiences they find specific Native Hawaiian foods like kalua pig, faced is one that many Pacific Islanders can relate pork laulau, and poi alongside foods from other to. Many Pacific Island subgroups have also ethnic backgrounds like malasadas (Portugal), experienced cultural disintegration and trauma poke (Japan), and pork adobo (Filipino). (Crabbe, 1998).

Native Hawaiian Culture Cultural Immigrations Culture describes the rituals, traditions, system of Here is a brief review of cultural immigrations beliefs, spirituality, religion, language, behav- after Europeans first contact (Table 11.3). ioral norms, ways of communication, and learn- The rich ethnic diversity of Hawaiʻi provides a ing knowledge. Culture can serve as a bridge wealth of cultural influence and the Native between multiple dimensions of life, as well as Hawaiian people have historically embraced the supporting the development of a greater under- introduction of new cultures. Native Hawaiians stand of oneself and others. Native Hawaiians have a long history of accepting and identifying tend to view themselves collectively, consider others as being part of their “hānai” or adopted multiple perspectives, and interpret themselves family and having no prejudice around interracial through ecological, historical, and cultural con- marriage. The residents of Hawaiʻi embraced the texts. They tend to see group goals as more cultural influences of others and did not carry a his- important than individual goals (Oliveira et al., torical dislike of other ethnicities. Consequently, 2006). As previously mentioned, the Hawaiians the development of a “hapa” or mixed race began as well as other Pacific Islanders had a sense of early in the history of Native Hawaiians. It is cul- harmony or lōkahi from nature (ʻāina), human- ture rich with embracing and engaging in multiple kind (kanaka), and spirits (akua). This can be cultural practices and identities. In the USA, the shown below in Fig. 11.3. The ultimate goal was 11 Behavioral Health Service Delivery with Pacific Islanders 149

Table 11.3 Hawaiʻi racial immigrations timeline (adapted from McDermott & Andrade, 2011)

to elevate one’s earthly presence to a place where psychological, and spiritual can be seen. The health and prosperity was gotten for all (Cook, term ʻāina includes one’s ancestral home as well Withy, & Tarallo-Jensen, 2003). Within these as substances required to nourish the body. A terms, the complex interaction between physical, psychological ʻāina refers to positive and nega- 150 L. A. Duke and H. Foster

Fig. 11.3 Depiction of the view of Hawaiians

tive thinking that constitutes mental health. among ethnic minorities. Many studies have Spiritual ʻāina refers to relationships with the been devoted to understanding the reasons for spiritual world. A well-known Hawaiian proverb these disparities and how to better address them. is “Aloha aku, aloha mai” or “give love, get love,” Some of the major hypotheses were access to which shows the belief that if one gives love care, lack of buy-in when care was available, freely, it will come back to that person. There is premature drop-out, and finally that ethnic also the belief of mālama, which means to care minorities were not included in original samples for, and can be applied to all things. There is a determining efficacy of interventions and that belief in acting pono, or righteous, which works treatment effectiveness may differ in different to achieve balance or harmony. In this case, one populations. Matching cultural beliefs may must act pono to achieve lōkahi with the body, underlie many of these variables (Oliveira et al., mind, and spirit. Understanding specific terms 2006). For example, problematic behaviors in within a culture can elucidate important values. Western culture is viewed as a problem with the individual or their culture, whereas within Pacific Islander cultures problematic behaviors Part II Working with Pacific are often viewed as being caused by an imbal- Islanders ance between relationships and emotional bonds (Marsella, Oliveira, Plummer, & Crabbe, 1995). Is Culturally Adapted Therapy Additionally, if the proposed treatment does not Necessary? fit within the cultural beliefs of the individual they may not be interested in pursuing treatment Both the growing diversity in the USA and the or may drop out prematurely. Focus groups are critical call of addressing health disparities in often used to gain information on diverse popu- minority populations have resulted in a dramatic lations. Native Hawaiians were asked about their change in the number of studies including ethnic priorities and concerns in terms of their health minorities, with Pacific Islanders as one of the care in a series of focus groups (Kamaka, more recent populations (Huey, Tilley, Jones, & Paloma, & Maskarinec, 2011). They identified Smith, 2014). Initial studies documented high (1) an importance of customer service with com- levels of medical and mental health disparities plaints of long wait times and short visits, as 11 Behavioral Health Service Delivery with Pacific Islanders 151 well as long wait times for results (2) wanting to A study by Benish et al. (2011) not only feel respected, and cared for (3) providers who compared culturally adapted treatments to both were good communicators and good teachers (4) a control group and the evidence-based treat- thoroughness of care, which would include ment, they also determined if adaptation to a understanding reservations or fears (5) costs. In person’s cultural explanation of how illness traditional Pacific Islander views, healing for the occurs was the sole moderator of better results. physical body cannot occur without setting right Other factors that have been evaluated as mod- any problems within the mental or spiritual erators include where the interventions are pro- realm (Fig. 11.3). Utilizing the cultural approach vided, individual versus group, diagnosis, age, could help to motivate behavior change through language match, and ethnic match of the pro- a willingness to try new behavior. Even within vider (Degnan et al., 2018; Hodge, 2010; Huey the medical community, culturally specific inter- & Polo, 2008; Rojas-Garcia et al., 2015). One ventions have found success. In treating diabe- study found that of all the ethnic groups, Asian tes, the PILI Ohana Pilot Project (Mau et al., Americans benefitted the most from culturally 2010) for Chuukese, Filipino and Samoans uti- adapted interventions (Rojas-Garcia et al., lized a community based participatory research 2015). Overall, the majority of adaptations (CBPR) design. Members of the communities to address areas of language, communication, con- be targeted devised important themes in control- text, family, content, delivery, therapeutic alli- ling diabetes. They identified food related issues ance, and treatment goals (Degnan et al., 2018). (e.g., cost and cultural eating expectations), In addition to treatment effectiveness, variables physical activity related issues (e.g., group exer- like increased participation and therapy reten- cise), social support issues (e.g., changes are tion are important in reducing health disparities made by whole family and time management), and may be improved with cultural adaptations. and community assets within the three domains Estimates of increased family engagement for of social/community, family, and individual. culturally adapted interventions are 40% These domains were then utilized to derive a (Kumpfer, Magalhaes, & Xie, 2017). Cultural conceptual model of weight loss specific for adaptations may be more cost-effective than these populations with their specific needs, bar- cultural interventions designed from the ground riers, and strengths in mind. up (Kumpfer et al., 2017), although interven- There have been numerous studies evaluating tions from the ground up utilize the community cultural adaptations of mental health services for from initiation of the idea throughout the inter- non-Western populations with mixed results vention and are fully vetted within the commu- likely related to methodological heterogeneity nity likely leading to even higher levels of and range of adaptations utilized. A review of community participation. meta-analyses determined overall effect sizes of cultural adaptations range from 0.23 to 0.75 (Rathod et al., 2018). The meta-analysis by Other Cultural Considerations Griner and Smith (2006) indicated effect sizes of 0.46. Huey and Polo’s meta-analysis in 2008, Despite the use of cultural adaptation, caution which evaluated behavioral health treatments for should still be used to be mindful of subgroups ethnic minority youth, had a small effect size and like sexuality or poverty. Many ethnic minorities inconsistent quality (Rathod et al., 2018). A are also often dealing with chronic stressors meta-analysis conducted by Benish, Quintana, related to low socio-economic status (SES). In and Wampold (2011) included both published fact, because these two factors are so inextricably and unpublished studies and found an effect size woven within the USA, it is hard to determine the of 0.32. This is lower than subsequent meta- influence of one without the other. There have analyses and may be related to including too been numerous articles discussing the increased many studies that lacked scientific rigor. rate of chronic adverse events that those in a 152 L. A. Duke and H. Foster lower SES are exposed to (Schieman & Koltai, Table 11.4 Elements to ensure cultural competency 2017). Low SES is also highly disproportionate (Kaholokula, 2013) in chronic health disparities and is consistently Elements to ensure cultural competency associated with poorer mental health, poorer aca- • Knowledge and understanding of cultural norms demic achievement and employability (Blustein • Understanding client’s conceptualization of mental illness and variables influencing it et al., 2002; Goodman & Huang, 2001). • Culturally appropriate assessment strategies • Culturally relevant treatment when applicable and incorporate native practices and values Cultural Competency • Development of evidence-based treatment • Ongoing re-evaluation of self and the patient to Culturally adapted interventions may be an assess current practices and effectiveness • Appropriate discharge planning that is reflective of important step in decreasing health disparities, services available in the community but the other crucial component is cultural competence within the health professional (Dinos, 2015). Cultural competency includes under- nect with others. Pacific Islanders tend to be standing the role of culture in understanding more perceptive to non-verbal cues. Haole the health beliefs, attitudes, and behaviors to be able term typically used to describe Caucasians to establish rapport and trust to promote proac- refers to lack of breath and symbolically tive health behaviors (Kamaka et al., 2011). referred to the distance that the European visi- Competence can also be seen as “accepting and tors had when they said hello. Traditionally, respecting differences and reinforcing the Hawaiians would exchange breaths (hā) with strength of the patient, family, community, or one another in close proximity with the fore- population in the process of engagement head and nose of the people involved touching (Betancourt, Green, Carrillo, & Ananeh-the other persons. When foreigners arrived to Firempong, 2003).” Cultural competence also Hawaiʻi and did not exchange breaths, involves being flexible and continually examine Hawaiians described them as haole, ʻole mean- one’s own belief system and how it interacts ing none and hā as in breath. This sharing of with the population of interest. Native Hawaiian breath is a sacred tradition that can be found patients have described the importance of having within other Pacific Islands as well. In working culturally competent providers (Kamaka et al., with this population, I believe that this is the 2011). By understanding culture, we may under- most critical piece and has also been identified stand how people view the health care system, in best practices (Kalibatseva & Leong, 2014). seek help, or are reluctant to seek help because People can quickly determine if their service of shame. The cultural competence described in provider has poor intentions or is not willing to this chapter is distinct from the term “cultural do what it takes to get to know the “patient” and competency” when used to refer to traditional their circumstances or if they “are working healers who provide specific traditional healing from their heart.” This is one reason for prefer- practices by those who are “island-born” and are ence of working face to face with providers so taught by elders or kupuna. Table 11.4 below they can judge intent, sincerity, and trustwor- shows elements proposed to enhance cultural thiness (Kaholokula, Ing, Look, Delafield, & competency in working with diverse populations Sinclair, 2018). Commonly, Pacific Islanders (Kaholokula, 2013). try to identify commonalities with one another. They may ask questions like where your family is from, where you went to high school, and do Therapy with Pacific Islanders you know so and so. This could partially be due to Pacific Islander’s beliefs about having a spir- Working within this Pacific Islander commu- itual connection to ancestral place, with an nity requires a genuineness and ability to con- openness to the flow and use of energy, brings 11 Behavioral Health Service Delivery with Pacific Islanders 153 intention and understanding, and relates to the porating more work with extended family, past, present, and future (Oneha, 2001). This is which is very important with Pacific Islanders. also because it is culturally appropriate to Treatment of the whole person becomes partic- develop common interests before getting to the ularly salient in considering the high comorbid- specific needs of the provider, which is consis- ity of medical illness and mental health (Sokal tent with cultural values of “talk story.” et al., 2004). Protective factors against depres- Questions during the intake should also include sion and suicide in Asian American and Native family, extended family, community, and the Hawaiian/Pacific Islanders adolescents patients’ role in all of these (Whealin, Seibert- included individual and ethnic self-esteem, Hatalsky, Howell, & Tsai, 2015). Elements like bicultural language competence, spirituality, prayers to open and close sessions and group and good social support (Wyatt, Ung, Park, therapy can also be used. In general, experien- Kwon, & Trinh-Shevrin, 2015). Family culture tial activities like walking on trails or going in may also be seen as a protective factor for insu- the garden can help people to feel more natural lating Asian Americans/Pacific Islanders (Xu and give them the desire to open up in a differ- et al., 2011). Native Hawaiian youth report ent environment. The experience can also receiving informal support from multiple com- incorporate Pacific Islander values like talking munity (Medeiros & Tibbetts, 2008). As a com- about plants and protocols that guide human bined group Asian Americans/Pacific Islanders behavior that can be generalized to their current tend to have lower rates of psychiatric distur- situations of school or job or family. For exam- bance and substance abuse (Sentell et al., 2014) ple, knowing how to pick certain plants, asking than others. When examining the Pacific permission before taking the plant, and thank- Islander/Asian American groups separately, ing the plant for the sustenance. This can be Native Hawaiians had higher rates of hospital- generalized to a child engaging in respectful ization for depression, bipolar disorder, and behavior in the classroom and not taking things anxiety disorder than other Asian American/ from other children without permission or to Pacific Islander groups, although they had the recovering addict for not stealing. In the shorter lengths of hospitalizations (Sentell past, the Pacific Islanders were well known for et al., 2014). Understanding these statistics and being sustainable and taking only what they understanding history and cultural practices is a need. Take fishing, for example, Pacific first step towards becoming culturally compe- Islanders will take only what is needed for their tent (Table 11.5). community rather than overfishing. They would also take the bigger fish and return small fish to the ocean so they are able to grow. These examples illustrate the connection between the individual, others, and their environment. Table 11.5 Parallel strengths (Kaholokula, 2013) Hawaiian healing Wellness and Strength Based Models Western healing practices practices Focus on physical/ Focus on interpersonal psychological signs, or spiritual causes Wellness or strength based models tend to be symptoms and causes within preferred to illness models because wellness is the individual believed to be curable, whereas illness is not Organic or psychological Problem results from (Agnew et al., 2004). Furthermore, the relation- problem imbalance in relationships/life roles ship between patient and provider may become Treatment involves Treatment involves more distant if the “illness” takes precedence in medicine, cognitive prayers, herbs, and the relationship. The wellness model also tends restructuring, and lifestyle repairing imbalance to be very holistic and may be unique in incor- changes 154 L. A. Duke and H. Foster

Other Therapy Considerations factors that have reduced the stigma associated with receiving mental health services is the Equally important as gaining trust in this popula- almost universal healthcare in Hawaiʻi and our tion is understanding where our patients reside welfare system requiring mental health treatment and current stressors they face. Sometimes these for those claiming mental health issues as the rea- factors underlie behavior choices that may appear son for unemployment. as non-compliant to their providers. Considering Although great improvements have been these multiple levels of factors also directly ties made, there is much more that can be done once into the systems perspective that is inherent in there is an understanding of environmental fac- working with Pacific Islanders. Wyatt et al. tors a patient is facing. These socioeconomics (2015) have postulated an “ecological frame- can interplay with race/ethnicity and gender to work” in translating social determinant of health affect health inequity (Cooper, 2002). Factors, to behavior. They describe the three systems as such as poverty, homelessness, drug use, domes- microsystem (interpersonal relationship and tic violence, and multiple families in one living environment encountered on the day to day), space, involvement with Child Protective mesosystem (kinship networks and standards of Services (CPS) plays an important role in the practice), and macrosystems (institutional, politi- physical and mental health of a population. For cal, social, and economical aspects creating example, a patient with repeat visits for urinary social norms and expectations). In rural commu- tract infections may be related to having to hold nities, those that often have higher levels of pov- their urine for long periods of time because of erty also display resiliency factors like the limited access to restrooms. Having this under- community coming together to address common standing quickly opens up a dialogue between concerns (Berkes & Ross, 2013). the client and provider to explore other options. Understanding these factors for our patients Nutrition programs have been created to both may assist in reducing stigma associated with support proper nutrition for our patients and our seeking help, improve compliance with recom- farmers with doubling food stamps making mendations of providers, and improve health. access to healthy foods affordable. Socioeconomic One factor we have found as important in status has a strong relationship with mental health reducing the stigma of seeking behavioral health (Goodman, Slap, & Huang, 2003). In our popula- services is providing integrated care within all of tion, these economic and social stressors may the separate clinics in our large Community have been present for generations. It is not Health Center. In this model, we demonstrate to uncommon to work with an adult who is cur- the patient that we believe in holistic care, with rently involved in a domestic violence situation, the understanding that behavioral health needs their partner uses drugs, they live with 4 other are vital to address with typical medical care, adults and 7 children, they feel unable to work which is in line with Native Hawaiian/Pacific because of depression and irritability, have two Islander values of treating the whole person children at home, and the patient has diabetes. (Crabbe, 1998). A second point in the importance They may not have graduated from high school of considering other factors commonly experi- and do not have any family members who are enced in the Pacific Islander population served by currently employed or are in a “healthy relation- the Community Health Center is understanding ship.” Chronic exposures to these stressors in and devising alternative solutions to barriers in addition to cultural factors of discrimination, treatment. Mental health issues may become prejudice, intergenerational trauma have been even more important in treating chronic pain and associated with higher levels of aggression, substance use, although we also believe that incarceration, and mental health issues (Baker, keeping individuals mentally healthy at various Hishinuma, Chang, & Nixon, 2010). Chronic stages in their lives also leads to children and stress may also impair brain development in families who are more healthy. A couple of other executive function and regulation of impulses 11 Behavioral Health Service Delivery with Pacific Islanders 155

(Romeo, 2013). Developing this knowledge can as acculturation, marginalization, discrimination, enhance understanding of the patient, be able to generational status, and language proficiency cater treatment based on the needs of the patient have all been shown to be correlated with depres- meaning more sessions may include problem sion and suicide in Asian American and Native solving for getting basic needs met, and concep- Hawaiian/Pacific Islander adolescents (Wyatt tions of positive outcomes. Practical et al., 2015). Many family variables, particularly considerations like providing shorter sessions, family conflict and bullying in school were iden- availability of childcare or being able to bring tified as risk factors, which means intervention children to the session (Dinos, 2015) make it programs focused on decreasing bullying and much more likely for patients to seek and con- family violence can be impactful for suicide pre- tinue care. vention. In fact, there have been multiple wide scale suicide prevention programs that were col- laborations between UH JABSOM and commu- Specific Culturally Adapted nity sites. The first of these, Hawaiiʻs Caring Treatments Community Initiative, a community based participatory approach (CBPR) brought training to Are there evidence-based culturally adapted community agencies and schools to help individ- interventions for Pacific Islanders? Many uals, adolescents and providers recognize suicide evidence-based practices have been imple- risk factors and empower adolescents and adults mented with efficacy and include cognitive to get additional help (Chung-Do et al., 2015). behavioral therapy, emotional competence, fam- The first step was enhancing the community net- ily strengthening, and improving physical health works to appropriately respond to suicide and the and well-being (Carlton et al., 2006). second arm of the program was empowering our Intervention studies generally pertain to specific youth as leaders to help other youth and as part- symptoms or behaviors. Only a few of the many ners in the project based on the BRAVEHEART adaptations that are regularly employed with (Building Resistance Against Violent Pacific Islanders have been published. These Environments thru Honorable, Empowered And will be reviewed in the following section and Resilient Teens) curriculum that has been vali- some of the other notable interventions utilized dated in other minority communities (Chung-Do with this community. et al., 2015; Sugimoto-Matsuda & Rehuher, 2014; Wilcox et al., 2011).

Depression and Suicide Post-Traumatic Stress Disorder There are several studies that have investigated and Trauma depressive symptoms and suicidal ideation. In Asian American/Pacific Islander youth depressed The Koa program was developed to treat PTSD symptoms worsened in later adolescence, and in veterans for veterans living in rural Hawaii were more prevalent in females and those who (Whealin et al., 2017). The program is an used alcohol and tobacco (Wyatt et al., 2015). For 8-session psychoeducational program utilizing suicide, Hawaiian adolescent females were at Pacific Islander values, beliefs and healing with higher risk than other Asian American ethnicities empirically validated cognitive behavioral ther- (Nishimura, Goebert, Ramisetty-Mikler, & apy (CBT) treatment. The program was delivered Caetano, 2005). Sexual minorities were at higher to remote locations through telemedicine and risk of suicide in Guam than other Asian included veteran’s family members. The inter- American and Pacific Islander adolescents vention workbook was modified to match lin- (Bostwick et al., 2014; Pinhey & Millman, 2004). guistic, educational, and cultural needs on both Specific factors related to ethnic minorities such surface and deep structure. 156 L. A. Duke and H. Foster

The Children’s Association of Mental Health ment of purpose), moʻokuaauhau (geneology), Division of the State of Hawaii has also devel- ʻoli (chanting), ka huakaʻi (migration), moʻolelo oped a culturally based program for treating (storytelling), ʻike hana lima (craftmanship), trauma in girls. The Kealahou Services program paʻani kahiko (ancient games), hoe ka waʻa collaborates with Hawaii’s child-serving agen- (canoe paddling), hula basics to teach precision, cies, communities and families to help girls build self-discipline, perseverance, and spiritual con- and nurture healthy relationships that will allow nection, ohana day, mālama ʻāina in the loi, and them to reconnect with their families, communi- Native Hawaiian crafting). They also include ties and themselves. other important skills for their patients to learn with smoking cessation classes, health and nutrition classes, physical recreation opportunities, Severe Mental Illness gender specific process groups, cinema therapy, financial literacy and several other living skills A meta-analysis regarding culturally adapted classes. interventions for schizophrenia across different cultures and categorized the types of interventions. In regards to communication, reparative Incarcerated Youth action and balancing needs of mutual respect and avoidance of confrontation for Chinese cultures An evidence-based treatment regarding mindful- was effective (Degnan et al., 2018). Other studies ness, the Mind Body Awareness Project included incorporation of spiritual or traditional (Himelstein, 2011) was culturally adapted for practices. There was a significant relationship work with Native American Youth (Le & Goebert, between the number of adaptation and better total 2015) and further adapted for use with Pacific symptoms (Degnan et al., 2018). There is another Island Incarcerated Youth (Le & Proulx, 2015). chapter on cultural adaptations for treating severe Mindfulness was tied to the literal meaning of mental illnesses including bipolar disorder. aloha and breath. Patients were advised to con- Rathod, Kingdon, Pinninti, Turkington, and Phiri nect their breath to their connections of them- (2015) also authored a chapter on cultural adap- selves and their culture. tations that can be applied for use with Pacific Islanders including how to use cultural influences to improve medication compliance and identify Other Pacific Islander Models triggers for mood changes or psychosis. They suggest using regular family or cultural activities Samoan Models to support treatment plan, to improve medication Faafaletui Model, alternatively called the adherence, help reduce stress and for discovering Wellington model and was produced by the other strengths of the individual. Wellington Family Centre (Tamasese, Peteru, & Waldergrave, 1997). It loosely refers to holding an investigation on a particular matter. There is Substance Abuse Treatment similarly a traditional Samoan healing treatment, which included traditional elements of the tradi- One of the most efficacious substance abuse tional massage (fofo) and of the healers who car- treatments on Oahu is Ho‘omau Ke Ola. They ried out the traditional fofo practices (i.e., to the utilize a combination of Western curriculum taulasea or tohunga). There are also special herbs, ((CBT), dialectical behavioral therapy (DBT), oils and liquids used in traditional Samoan prac- trauma-informed care, social skills training, tices. Similar to other Pacific Island cultures, 12-step familiarization classes) and culturally their traditional practices are handed down in specific curriculum (kūkulu kumuhana (state- families or to other people who show promise. 11 Behavioral Health Service Delivery with Pacific Islanders 157

New Zealand are being addressed. Another author used the The Fonofale (MoH, 1997; Pulotu-Endemann, Incredible Years curriculum to strengthen parent- cited in MoH, 1995) model was described as one ing and reduce mental health issues, which was of the key holistic models to address New Zealand used effectively with Chinese Americans and health needs. Another model was termed woven Korean Americans (Kim, Cain, & Webster- strands or Pandanus model which means the dif- Stratton, 2008; Lau, Fung, & Yung, 2010). Flores ferent strands in a case cannot be all woven et al. (2015) implemented the program through together in the same way. “Responding to the catechism classes. Participants reported that it needs of a Pacific consumer and his/her family improved positive reinforcement and taught new therefore requires recognition of the heterogene- techniques like setting rules, teaching responsi- ity of Pacific problems. Weaving together the bility, and improving quality time. Other benefits strands of the Pandanus mat was raised as a meta- were increase of social support for parents and phor for how the different strands of a (mental children. health) case are woven together. The point being that the strands interlock to form a whole and that the mat’s durability depends on how well the Training Future Practitioners strands are woven together. The suggestion is that like a good Pandanus mat, a good health and Hawaii has 14 Federally Qualified Health Centers wellbeing model requires that all the key strands on six islands that provided care for 150,000 of a person’s life needs to be well thatched to be patients in 2016. The FQHCs serve the rural and able to withstand the test of time and different low-income residents on all six islands who elements.” The canoe theme mentioned at the would otherwise lack access to primary care ser- beginning of this chapter was described as the Te vices. The FQHCs are the largest provider net- Vaka model. work for Medicaid and second-largest provider source of direct primary medical services in the Filipino’s state. There are American Psychological Filipino’s have different values from other East Association (APA) psychology internship train- Asian American cultures since they were colo- ing sites at several of these community health nized by the Spanish (Javier et al., 2014). Cultural centers. This section will describe the psychol- values that may correspond to lower levels of ser- ogy training program for one of these Federally vice utilization include a belief in fatalism (bhala Qualified Community Health Centers on the na), shame (hiya), cultural mistrust and collectiv- island of Oahu. ism (Javier et al., 2014). In their community Beginning with interviews, each applicant to engagement study where they utilized a combi- our large community health center serving pri- nation of focus groups and quantitative analyses, marily Pacific Islanders is taken on a tour of the they identified four ways to more effectively campus, which describes the many buildings and engage Filipino adolescents in mental health ser- services provided, as well as the history of the vices. They discussed strengthening parent-child Health Center and culture of our community and relationships with improving communication and patients. Many other features of the campus are spending quality time. They also suggested pro- highlighted such as patient gardens with tradi- viding parenting programs to address this need. tional and medicinal plants, walking trails, and Specific suggestions were that the parenting style fitness center. When students come to the health used in the Philippines may not be effective in the center for training, they are immediately exposed USA, which included “put-downs” and “verbal to Native Hawaiian culture. There is a welcome shaming.” Because of the importance of religion, ceremony, beginning with a traditional Hawaiian inclusion of cultural leaders or messages through protocol, involving chanting. The chant intro- church can be helpful in necessary components duces the students and asks for permission to and in ensuring that parent mental health needs enter. There is a welcoming chant that describes 158 L. A. Duke and H. Foster the attributes of the Health Center in terms of some of our patients, and a slight increase in self- spirituality, the site, and the patients we serve. disclosure may help to facilitate connection with The student group will also bring symbolic offer- some patients. Psychology services may include ings to health center directors and be greeted with more case management and holistic care. Our leis. The students are then welcomed by current health center prides itself on integrated care so support staff and providers, and each person behavioral health providers are part of a multidis- shares something about themselves and serving ciplinary team in various clinics. Therapists must our population. Students are reminded that the also consider Maslow’s hierarchy of needs when most important virtue is a willingness to serve treating patients and ensuring that basic needs and a caring heart, which is directly related to the (e.g., food and shelter) are met prior to address- perceptions of our patients. This formal cere- ing more higher-order challenges. This also mony is followed by a typical orientation day of needs to be considered when assigning home- obtaining badges; review of training handbooks, work or with other aspects of therapy. As a result, policies, and procedures; documentation; and depending on the patient or presenting problem, HIPAA and Electronic Medical Records training. therapy may be more solution focused. They are In the beginning of the year, there are focused also taught to consider our patients’ perspective full-day experiential cultural trainings within the of more collective goals and harmony among communities where our patients reside. Students others. Patients can be specifically asked in goal are taken to heiau (religious sites), homeless setting which area of the lokahi triangle they encampments to see the culture of our patient need to work on. communities and possible barriers to care, and Our trainees also gain experiences in research through local communities to gain a further with vulnerable populations. They are exposed to understanding of and enhanced connection to the the safeguards in place for ensuring that research culture of our patient population. The other com- is done for the benefit of the community, and to ponent of this full-day training is beginning to different levels of community based research. share with students the stories of the Native They also gain first-hand experience of recruit- Hawaiian’s (moʻolelo), discussing values and ment in hard to reach populations. increasing readiness (hoʻomākaukau) to provide services by clearing one’s own mind, body, and Acknowledgments Additional heartfelt mahalo to the feelings. interns of Community Health Center 2017–2018 training The students continue to receive training year, Kasha Kim, Ciara Hansen, Leila Mitsunaga, Micah Keaney, and Kellen Imada as well as our training director throughout the year on culturally mindful care in Kristy Sakai-Costigan, Psy.D. for their critiques and revi- individual and group supervision, through direct sions of this chapter, as well as their excellence in all clinical experience with patients, and weekly aspects of our patients care. didactics on relevant topics that include cultural considerations or relevance to our population. 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Ana J. Bridges and Aubrey R. Dueweke

Introduction expected to near 25% by 2065 (Pew Research Center, 2017). Approximately two-thirds of It is a near certainty that clinicians will, at some Latinos living in the USA are Mexican origin, point, work closely with Latinx clients, likely 10% are Puerto Rican, 4% are Salvadoran, 4% some who were born outside of the USA and Cuban, 3% Dominican, 2% Guatemalan, with the many who will be fluent in Spanish with limited remaining groups each comprising <2% of the English proficiency. In this chapter, we provide Hispanic population in the USA (Pew Research an overview to help introduce clinicians to the Center, 2013; US Census Bureau, 2016). Latinx population in the USA and how historical, Approximately one-third are born outside of the cultural, and adjustment experiences may be USA. Among US-born Latinos, 69% speak important to consider when providing treatment. English fluently, while among foreign-born After describing the rich, diverse cultures that Latinos, less than 35% are fluent in English. comprise the Latinx population, we provide sug- Although Latinos share a common geography gestions for delivering behavioral health services (spanning from North to Central and South in an engaging and culturally informed manner. America, including the Caribbean) and language These suggestions are presented by phases of (primarily Spanish, but also some speak treatment, from intake to termination. Together, Portuguese or native languages, such as they provide a baseline from which clinicians can Quechua), there are important differences among branch out to learn how to work effectively with the major subgroups of Latinos in the USA, and their Latinx clients. important generational differences (see Table 12.1). Different decades have seen different waves of migration to the USA from Latinx Latinos in the USA countries. The history of Latinos in the USA is part of the history of the USA. Spaniards were Since 2003, Latinos have comprised the largest the first to land in the Americas from Europe minority group in the USA, surpassing African (Schwab, 2018), and parts of what is now the Americans. Currently, approximately 18% of the USA were originally settled by the Spanish. For US population is Latinx, and the percentage is instance, current day New Mexico, Texas, and California were originally Spanish territories. In A. J. Bridges (*) · A. R. Dueweke fact, Texas was part of Mexico until 1845, when Department of Psychological Science, the USA officially annexed Texas. The Homestead University of Arkansas, Fayetteville, AR, USA Act of 1862 allowed US residents to settle and e-mail: [email protected]

© Springer Nature Switzerland AG 2020 163 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_12 164 A. J. Bridges and A. R. Dueweke

Table 12.1 Demographic differences by Hispanic subgroups in the USA (Pew Research Center, 2013) Median annual % % College personal % No Country of % English Median % educated income (age % In health % Home origin US-born fluent age Married (age 25+) 16+) poverty insurance owners Argentina 38 74 35 56 40 $30,000 11 22 53 Colombia 36 60 34 47 31 $24,000 13 27 49 Cuba 42 60 40 45 25 $24,400 19 25 56 Dominican 44 56 28 35 16 $20,000 28 21 25 Republic Ecuador 38 53 32 46 19 $22,000 18 32 40 El Salvador 40 48 29 42 7 $20,000 23 39 41 Guatemala 36 43 27 40 7 $17,000 29 46 30 Honduras 36 47 28 36 8 $17,500 33 46 29 Mexico 65 66 25 45 10 $20,000 28 33 49 Nicaragua 40 62 32 44 20 $22,000 18 31 44 Peru 32 60 35 47 31 $24,000 13 28 50 Puerto Rico 99 82 28 35 16 $25,000 28 15 37 Venezuela 31 68 32 49 51 $25,000 15 26 48 All 64 66 27 43 13 $20,000 26 30 46 Hispanics General US 87 – 37 48 29 $29,000 16 15 65 population claim lands in the West, lands that had until then Immigration to the USA from Latin American belonged to Mexicans. In 1917, Puerto Ricans countries has accelerated in the past few were officially granted US citizenship. Just a few decades. Economic and political factors in years later, the US Congress began to limit the Latinx countries were largely responsible for number of immigrants allowed to enter the USA many waves of migration to the USA in the mid- (until that time, there was no “legal” or “illegal” to late twentieth century (Tienda & Sanchez, entry system) and subsequently created a border 2013). Fidel Castro rose to power in Cuba (late patrol. In 1932, the USA began deporting 1950s), aligning Cuba with communism and the Mexican immigrants for the first time. It was not Soviet Union, leading to massive exile of upper- until 1954 that the US Supreme Court formally and middle-class, highly educated Cubans to recognized the discrimination and inequality Miami. In the 1950s and 1960s, many Latinos Latinos in the USA experience (in Hernandez v. from diverse countries such as Argentina, The State of Texas), followed later by the Civil Mexico, and Colombia came to the USA because Rights Act of 1964 that prohibited discrimination of limited economic opportunities in their coun- on the basis of gender, race, or ethnicity. In the tries of origin. In the 1970s, military dictator- mid-1970s, the Equal Educational Opportunity ships in Argentina and Chile and civil war in El Act paved the way for public schools in the USA Salvador lead many people to immigrate to the to offer bilingual programming to students. In USA, fleeing violence and repression. More short, while Latinos have been part of the US recently, concerns about lack of economic geographical landscape since the country’s ori- opportunities, gang violence, natural disasters, gins 200+ years ago, it has only been in the past drug cartels, and continued political unrest 50 or so years that efforts to address disparities have resulted in additional immigrants from and inequalities have been formalized by the leg- Mexico, El Salvador, Honduras, Guatemala, and islative and judicial branches of the government. Colombia (Holmes, 2018). 12 Behavioral Health Services in Latinos 165

Stressors and Mental Health & Harvard T. H. Chan School of Public Health, 2017). A similar proportion encountered dis- Compared to non-Latinx Whites, Latinos resid- crimination when attempting to rent or purchase ing in the USA tend to experience similar or bet- a home. Over 25% reported experiencing dis- ter overall mental health. For example, a national crimination in the context of law enforcement. epidemiological study found comparable rates Central to the topic of this chapter, 20% of of lifetime anxiety disorders, depressive disor- Latinos polled reported experiencing discrimi- ders, impulse control disorders, and substance nation in the health care setting and a nearly use disorders in Hispanic and non-Hispanic identical number reported they would rather White adults overall (Breslau et al., 2006). avoid seeking care than to face such poor However, when examining group differences for treatment. specific disorders, the only significant differ- The types of discrimination the majority of ences found favored Hispanics. For example, Latinx people reported experiencing were verbal Hispanics had rates of generalized anxiety that insults or offensive/insensitive comments; how- were nearly half that of non-Hispanic Whites ever, a large portion had also been threatened, (4.8% vs. 8.6%). Similarly, lower rates of social experienced violence, or been sexually harassed phobia (8.8% vs. 12.6%), dysthymia (2.2% vs. (NPR et al., 2017). Experiences of discrimina- 4.3%), and major depression (13.5% vs. 17.9%) tion may differ, however, in different subgroups were observed. However, this global picture of Latinos, in part because of associated sociode- masks important subgroup differences within mographic differences such as acculturation, the Latinx population. For instance, compared age, and socioeconomic status (Anderson & to Puerto Ricans, Mexican-origin Latinos expe- Finch, 2017; Arellano-Morales et al., 2015). In rience lower rates of lifetime depressive disor- addition, Latinos residing in cities with large ders, while Cubans experience lower rates of Hispanic populations (e.g., Miami, San Diego) substance use disorders (Alegría et al., 2007). tend to report lower discrimination than those Furthermore, compared to US-born Latinos of living in cities where Hispanics comprise a any country of origin or Latinos who speak smaller proportion of the population (e.g., English well, immigrants and Latinos with low Chicago; Arellano-Morales et al., 2015). The English fluency experience lower rates of life- NPR poll (NPR et al., 2017) found an associa- time substance use and psychiatric disorders. tion between education, birth region, and dis- This is consistent with prior work suggesting a crimination in ways that are perhaps surprising: possible negative impact of acculturation on the well-educated Latinos and those born in the mental health of Latinos (Ortega, Rosenheck, USA actually reported greater instances of expe- Alegría, & Desai, 2000). riencing discrimination, perhaps because they Latinos in the USA may face unique stress- interact more with other groups or because they ors that can impact their well-being. These pri- are more aware of subtler forms of discrimina- marily include discrimination, acculturative tion (called microaggressions; Anderson & stress (difficulties adjusting as an immigrant Finch, 2017). because of financial or language barriers, loss of social networks and status, family conflict, etc.; Caplan, 2007), and vulnerability due to immi- Ethnic Identity gration policies and laws (Schwab, 2013, 2018). A recent national poll found approximately one- Ethnic identity can be loosely defined as the third of Latinos living in the USA experience sense of belonging or commitment to an ethnic discrimination, oftentimes in the context of group (Smith & Silva, 2011). It is thought to work (e.g., applying for jobs, equal pay, and develop in a dynamic manner throughout the opportunities for promotion) (National Public lifespan, particularly in adolescence and early Radio (NPR), Robert Wood Johnson Foundation, adulthood (e.g., French, Seidman, Allen, & Aber, 166 A. J. Bridges and A. R. Dueweke

2006; Phinney, 1993) and includes cognitive, General Approach to Treatment behavioral, and emotional components. Processes such as acculturation and enculturation are key to Altogether, the diversity of the Latinx population the development of one’s ethnic identity. in the USA, the recognition of ethnic identity as a While the broader US culture may group developmental, dynamic process, the limitations together everyone from Latin America or of panethnic labels, and the recognition of the Spanish-speaking countries into what is called a intersecting components of social characteristics “panethnic” group (e.g., Hispanic or Latinx), a we all have (some of which are valued and some significant minority of Latinos do not identify of which are devalued by the contexts in which with such broad panethnic labels and instead we find ourselves) make sweeping generalized identify with their country of origin (e.g., statements about the treatment of any group of Salvadoren, Argentinian) (Pew Research Center, people limited in their utility. Therefore, we cau- 2012). Most Latinos say they do not share a com- tion the reader to note that what follows is a set mon culture with people of other countries of ori- of recommendations we make based on scholars gin, even if there is a shared language (Pew who have devoted their careers to understanding Research Center, 2012). the mental health needs of Latinos in the USA, Complicating even further the issue of ethnic but typically those recommendations arise from identity is the notion of intersecting identities. largely Mexican, largely recent immigrant, and Increased attention has focused on the myriad largely working class groups. It is imperative for ways people are diverse—despite sharing some clinicians to assess each client, to consider the characteristics (e.g., being of the same country ways the client identifies—including the strength of origin), people differ in gender, sexual orien- of a Latinx identity but also other identities—and tation, generation status, physical ability, gen- then weave those components that are most cen- der expression, socioeconomic status, tral to the self into the approach the clinician educational attainment, and so on. The term takes in therapy. Stated differently, and at the risk “intersectionality” refers to the many social sys- of stating the obvious, just because a particular tems of privilege and oppression a single person client identifies as Latinx (or Hispanic, or can encompass, and how this configuration is Venezuelan, or Puerto Rican) does not mean all woven into the way a person experiences the or even any of the recommendations that follow world (Crenshaw, 1989). For instance, while will be important for therapy. being White and male are each, individually, characteristics associated with social privilege, a gay White man or a Black heterosexual man Prior to Intake may experience the world through the lens of both his privilege and his marginalized statuses. Many scholars who have written about cultural Similarly, a Mexican woman with a doctoral competence agree on the importance of self- degree may experience the world complexly awareness when working with a diverse client through her marginalized and privileged sta- base (Rust et al., 2006; Sue, Zane, Nagayama tuses in ways that will differ from those experi- Hall, & Berger, 2009; Trimble, Scharrón-del-Río, enced by a Mexican male from a working class & Hill, 2012). The first step towards building background. In short, ethnicity is but one com- self-awareness involves actively exploring one’s ponent, and perhaps not even an important com- own biases, beliefs, cultural norms, values, and ponent, of any given person’s identity. Other worldview. Some questions therapists may want aspects of identity (skin color, gender, educa- to ask themselves during this process include, tion, sexual orientation, geographic origin) may “How central is my ethnic and/or cultural identity proffer privilege or serve as a source of margin- to my sense of self?” “What are my values?” alization in ways that shape an individual’s “What are my personal ‘hot button issues’ that identity. could lead me to misjudge or miscommunicate 12 Behavioral Health Services in Latinos 167 with others?” and “How does my cultural back- culture? Is the website available in multiple lan- ground, including my educational experience, guages? Is there a policy or strategy to include influence my way of thinking about mental health language interpretation services? Are forms (con- and treatment?” For instance, a young therapist sent forms, intake paperwork) available in born and raised in the USA may value strongly Spanish or other Latinx languages? Do members egalitarian gender roles and may struggle if of the practice (staff, therapists, others) reflect working with a Latina client who subordinates diversity? Has the therapist established connec- her personal needs to those of her husband and tions with other local providers and organizations children. who serve Latinos? Are practice hours, locations, After answering questions like these and iden- and physical spaces (artwork, building access, tifying personal biases and beliefs, one must con- and so forth) welcoming to diverse clients? tinually examine how these may be influencing perceptions of and interactions with Latinx clients. Building self-awareness and cultural com- At Intake petence are ongoing processes, not an achievable end state (Caldwell et al., 2008). Providers who Intake interviews are typically the first points of wish to keep themselves accountable to the life- face-to-face contact clinicians have with their cli- long nature of these processes can work with ents, and thus provide a vital opportunity to set clinical supervisors and colleagues to bring dis- the tone for the remainder of the working rela- cussions about personal biases and beliefs to the tionship. Too often, clinicians will adopt a “color- forefront, with the goal of non-defensively con- blind” stance, taking each client as an individual sidering and challenging them throughout one’s stripped of their unique social identities or assum- career. ing the experiences of clients across ethnic Providers should also be mindful of the hubris groups are similar. Both approaches minimize the that often permeates academic and clinical train- unique experiences of ethnic minority clients ing, and work to counteract it. Humility is essen- (Neville, Spanierman, & Doan, 2006). This tial when working with clients who differ from should be avoided. At best, a color-blind stance one’s own cultural background or experience. leads clinicians to miss potentially vital pieces of Indeed, therapists who have not had much experi- information to case conceptualization, and at ence working with Latinx clients must be willing worst it can make minority clients feel silenced, to acknowledge the gaps in their knowledge and minimized, and oppressed (Sue, 2004). Instead, commit to learning from each individual they providers should strive to take a multicultural serve. It will also be important to refrain from approach to assessment and intervention, wherein making sweeping generalizations based on ethnic cultural differences are actively examined and group membership. Instead, clinicians should incorporated into treatment. Below, we review a treat each client as the expert on his or her own few steps therapists can take at the outset of treat- experience and, when unsure of whether a par- ment to foster a multicultural approach when ticular thought or behavior reflects that client’s working with Latinx clients. culture, ask. In addition to taking time to reflect on per- Be Mindful of the Power Differential Regard sonal beliefs about culture and values and a com- less of client or therapist cultural background, mitment to being open, humble, and eager to there is an inherent power differential in every learn from one’s clients, therapists should con- therapeutic relationship. These relationships are sider how the structure of their practices may largely one-sided, as clients are expected to convey a sense of comfort and approachability divulge their thoughts, emotions, reactions, and for Latinx clients (see, for instance, Siegel, behaviors openly to a relative stranger, with much Haugland, & Chambers, 2003). Does the practice less self-disclosure on the part of the therapist. In have a mission statement that includes aspects of cases where the therapist is a member of the 168 A. J. Bridges and A. R. Dueweke majority ethnic group (i.e., White) and the client By asking directly about these sociopolitical is a member of a minority ethnic group (e.g., stressors, the therapist models an open and hon- Latinx), this power differential is likely to feel est stance, and conveys that she is willing to even more substantial. The client may feel pres- wrestle with potentially uncomfortable topics sured to follow the therapist’s lead when it comes like privilege, oppression, discrimination, and to discussions of race and privilege, which could racism as they relate to mental health. Starting a be quite damaging if the therapist insists on mini- dialogue about these stressors early on in therapy mizing and ignoring the role of culture in the can serve to establish trust with Latinx clients, room and in the client’s life. Therapists who making them feel seen and respected (Muñoz & acknowledge the power differential and actively Mendelson, 2005). It also signals to Latinx cli- attempt to understand their clients’ worldviews ents that the clinic represents a safe space. will be able to build a stronger working relation- Undocumented Latinos often report fear of ship with their minority clients (Ibrahim, deportation as a deterrent from seeking mental Roysircar-Sodowsky, & Ohnishi, 2001). With health care (Bridges, Andrews, & Deen, 2012; this in mind, therapists working with Latinx cli- Rastogi, Massey-Hastings, & Wieling, 2012; ents should be ready and willing to take the lead Wells, Lagomasino, Palinkas, Green, & Gonzalez, on initiating conversations about the role of cul- 2013). Thus, depending on clinic policy, it could ture and ethnicity both in the therapeutic relation- be worth explicitly mentioning the clinic will not ship and as they relate to the client’s presenting maintain any information about or request proof concerns (Muñoz & Mendelson, 2005). In addi- of legal status, as a further safeguard to the cli- tion to fostering a strong working alliance, ent’s privacy and well-being (if this is indeed a assessing for and affirming cultural differences policy both the therapist and the clinic are com- will also allow therapists greater opportunity to fortable with). tailor and optimize their care plan for their clients. Assess for the Centrality of Latinx Culture and Cultural Values to the Individual As Inquire About Stressors That May Be Unique noted above, there is immense heterogeneity to Latinx Clients The presenting problems of among Latinos (Furman et al., 2009; Zsembik & Latinx clients are often embedded in a different Fennell, 2005), and the individual sitting in front historical, political, social, cultural, and eco- of a clinician may see being Latinx as core to nomic reality than those of non-Latinx White their identity, or they may not. Hence, clinicians clients. To make space for these differences, striving for cultural humility should assess the therapists should consider modifying their stan- centrality of a Latinx (or national) cultural iden- dard intake interview to inquire about the spe- tity to their Latinx clients, taking care not to cific sociopolitical factors that may be make assumptions about the client’s values based contributing to or maintaining their Latinx cli- on ethnic group membership. For example, a ents’ current difficulties. As mentioned earlier, therapist with knowledge about familismo, a cul- Latinos may be experiencing unique stressors tural value found in many Latinx countries that related to discrimination (Pérez, Fortuna, & emphasizes strong family bonds and loyalty to Alegría, 2008), acculturation (Da Silva, Dillon, the family group (Antshel, 2002), may be tempted Rose Verdejo, Sanchez, & De La Rosa, 2017; to show off his knowledge by saying something White, Roosa, Weaver, & Nair, 2009), stereotype like, “I know family must be important to you.” threat (Appel, Weber, & Kronberger, 2015; While this knowledge may be helpful, it would Gonzales, Blanton, & Williams, 2002), legal sta- be much better to simply prompt, “Tell me about tus (Cavazos-Rehg, Zayas, & Spitznagel, 2007), your family” and allow the client to explain and refugee status or family separation (Perreira, whether or not family ties are important to them Chapman, & Stein, 2006; Suárez-Orozco, personally. The humble therapist should ask their Todorova, & Louie, 2002). clients what they value and what would make 12 Behavioral Health Services in Latinos 169 them feel respected, take an open stance, and be about the cause of their problems, expectations of ready to simply listen and affirm their client’s how long their problems will last, perceived con- experience (Rust et al., 2006). sequences experienced as a result of their problems, and beliefs about controllability (i.e., On the other hand, having knowledge about whether the problem is under personal control traditional Latinx cultural values can be helpful and able to be addressed in treatment). It should to guide therapists as they consider therapeutic also involve a discussion about what “healthy” processes, interpret clients’ behaviors, enact would look like to the client. Although these interventions, and assign homework to their cli- types of questions are beneficial regardless of clients. For instance, knowing familismo is impor- ent ethnic background, they may be of particular tant for many Latinx people, when considering a importance when working with Latinx clients. plan to change behaviors (such as engaging in greater self-care activities for depression or First, asking these types of questions at intake reducing television viewing before bed for allows therapists to assess for the client’s mental insomnia), a therapist might consider asking how health literacy and attitudes toward mental illness others in the client’s family might respond to and treatment. Limited mental health literacy these potential behavior changes. As another may be a barrier to treatment-seeking among example, many Latinx clients value personal- Latinos (Cabassa, Lester, & Zayas, 2007, López ismo, which is a personal (more informal) rela- et al., 2009). Studies have shown that Latinos tionship with people, especially those with whom experiencing psychological distress are more they do business. A Latinx client may ask their likely than non-Latinx Whites to conceptualize clinician personal questions or expect some their problems as somatic, not just psychological degree of personal self-disclosure from their cli- (Varela et al., 2004), which may orient them nician. Therapists who are less aware of this towards seeking medical solutions. Having an value may consider such questions “out of idea of the client’s mental health literacy and ill- bounds” or seek to uncover the reasons why cli- ness perceptions at intake can allow therapists to ents are curious about their personal lives (e.g., enhance psychoeducation and potentially protect may interpret the behavior to mean the client is against premature treatment termination. Second, not respecting boundaries, or is avoiding a diffi- having an understanding of what clients tell cult topic). Knowing the extent to which such themselves about their problems will provide personal engagement is simply part of how a therapists with important information that can be Latinx client relates to others can help therapists readily incorporated into interventions to increase avoid pathologizing such behavior. On the other treatment engagement. It is important that, while hand, assuming behavior is due to cultural beliefs having this discussion, therapists attend to and and values, and not attempts to avoid a difficult express respect for the client’s explanatory model topic, is just as problematic. Therefore, therapists or beliefs about the nature and causes of their dif- should be knowledgeable about common cultural ficulties (Benish, Quintana, & Wampold, 2011). values but assess the degree to which these are Research has shown that clients have higher applicable for their individual clients. expectations of change, are more satisfied with progress, remain in treatment longer, and have Ask About the Client’s Understanding of greater symptom improvement when they per- Their Problems and Hopes for Treatment We ceive their therapist’s views about their illness to also recommend that clinicians working with be congruent with their own (e.g., Claiborn, Latinx clients take some time during the intake Ward, & Strong, 1981; Long, 2001). Even if a interview to ask about the client’s understanding client’s explanation about their difficulties seems of the nature of their problems and beliefs about unhelpful, preliminary validation of the client’s how to best approach treatment. This conversa- perceptions at the outset of treatment will likely tion could involve eliciting the client’s thoughts foster a positive relationship that will allow 170 A. J. Bridges and A. R. Dueweke

therapists greater leeway for proposing alterna- Chafey, & Domenech Rodríguez, 2009, p. 362). tive explanations later in treatment (Benish et al., Modifications can include changes to both the 2011; Kleinman, Eisenberg, & Good, 2006). psychotherapeutic process (e.g., treatment delivery, the therapeutic relationship; Sue et al., 2009; Orient the Client to Therapeutic Services in a Whaley & Davis, 2007) and to the content of Non-stigmatizing Manner Traditional models treatment. of therapy are grounded in Western cultural ideals and epistemology (Trimble et al., 2012), and Adaptations to Process There are several adap- parts of the therapeutic process may feel foreign tations to the psychotherapeutic process that or counterintuitive to Latinx clients, especially if practitioners should consider when working with they are less acculturated (Kouyoumdjian, Latinx clients. One obvious adaptation that will Zamboanga, & Hansen, 2003). Thus, providers be of particular importance for clients who are working with Latinx clients should conclude the not fluent English speakers is ensuring one’s intake interview by providing some brief educa- clinic has the ability to provide services in tion about the rationale for treatment, and having Spanish (either through bilingual providers or a collaborative discussion about expectations for trained interpreters). In a recent qualitative inves- therapy visits. When discussing treatment ratio- tigation of the effects of language concordance nale, clinicians should be wary of potentially and interpreter use on therapeutic alliance in a stigmatizing terms, taking care to replace them primary care behavioral health setting, Spanish- with more culturally responsive language. For speaking patients expressed a strong preference example, in cognitive-behavioral approaches it is for bilingual providers, citing benefits such as not uncommon for therapists to describe a per- greater privacy, an increased sense of trust, and son’s behaviors as “maladaptive,” or label one’s more accurate communication of ideas beliefs as “magical thinking.” Because of the (Villalobos et al., 2016). In the absence of bilin- potentially condemning tone of these phrases, gual providers, patients found the use of trained providers may consider using words such as interpreters to be incredibly helpful, given their “unhelpful” instead, serving to reduce the amount role in increasing access to care and facilitating of implied blame placed on the client. Taking communication with English-speaking providers time to orient Latinx clients to the therapeutic (Villalobos et al., 2016). services in a non-stigmatizing way will likely increase treatment engagement and reduce pre- Because of personalismo, a Latinx cultural mature drop-out (Hays, 2009; Swift, Greenberg, value that ascribes importance to friendly, per- Whipple, & Kominiak, 2012). sonal relationships (even in professional domains; Añez, Silva, Paris Jr., & Bedregal, 2008), providers should also try to foster a warm and person- During Treatment able relationship with their Latinx clients. This may take the form of increased self-disclosure or Recent meta-analytic findings support the notion involvement of the self in therapy, greater will- that making cultural adaptations to empirically ingness to engage in informal small talk before supported treatments results in superior treatment and after sessions, asking clients about family outcomes for minority ethnic group members, members, and making good eye contact to dem- compared to traditional, non-adapted treatments onstrate active listening (Uebelacker et al., 2012). (Benish et al., 2011; Smith, Domenech Rodríguez, When interactions between clients and therapists & Bernal, 2011). In the context of behavioral or clinic staff are perceived as warm and friendly, health service delivery, cultural adaptation refers this will likely serve to increase treatment to the modification of a treatment protocol to engagement among Latinx clients. Conversely, make it “compatible with the client’s cultural pat- therapists who adhere tightly to a businesslike terns, meanings, and values” (Bernal, Jiménez- style of interaction, deflect personal questions, 12 Behavioral Health Services in Latinos 171 and minimize attempts at forming a bidirectional than non-Latinx Whites (Bridges & Lindly, 2008; relationship may be seen as cold or unwelcoming Kouyoumdjian et al., 2003). These factors could to Latinx patients, thereby decreasing treatment interfere with a client’s ability to initiate and engagement (Antshel, 2002). maintain therapy, especially in the traditional Therapists may also want to consider engag- specialty mental health clinic model, where cli- ing family members in treatment, given the ents are expected to attend weekly hour-long Latinx cultural value of familismo, which empha- appointments over the span of several months sizes the importance of strong family bonds and (Snell-Johns, Mendez, & Smith, 2004). loyalty (Antshel, 2002). There are several ways Outpatient mental health clinics typically adhere clinicians can incorporate family members into to strict attendance policies (e.g., if a client treatment, if familismo seems to be important to misses three sessions in a row without canceling the client. One option would be to bring family ahead of time they are no longer eligible for members into sessions occasionally. If the client receiving treatment). However, clinicians work- is amenable to this approach, family members ing with Latinx clients should be aware of poten- could be brought in to give their perspective on tial external factors that could be prohibiting the client’s functioning and current difficulties regular attendance, and work with their clients (i.e., an assessment-focused session), or to col- directly to problem-solve and perhaps establish a laborate on a particular treatment plan (i.e., an more flexible attendance policy. intervention-focused session). For example, a client in the midst of planning outside-of-session Adaptations to Content In Benish and col- exposure exercises may wish to bring a support- leagues’ meta-analysis (2011) examining the ive family member into their appointment to efficacy of culturally adapted treatments, they assist with planning and troubleshooting these found not only that culturally adapted psycho- homework assignments, along with holding the therapies are more effective than unadapted, bona client accountable to completing them. Family fide psychotherapies, but also that the superior members could also be brought in for some of the treatment outcomes evidenced by culturally initial sessions focused on psychoeducation and adapted psychotherapies are driven by just one goal-setting. Even when family members cannot important moderator—incorporation of the cli- be physically present, therapists can still demon- ent’s illness myth into treatment. A client’s ill- strate a focus on the importance of family by ask- ness myth, also known as their “explanatory ing clients about family members’ thoughts on model,” refers to the client’s inferences about the and responses to their current difficulties, and types of symptoms they are experiencing, encouraging clients to involve family members in assumptions about the cause of their illness (e.g., outside-of-session practice and conversations psychosocial, supernatural, behavioral, physi- about treatment. Including family members in the cal), estimation of the course of their illness (e.g., treatment of Latinx clients can increase treatment acute, chronic), postulation about consequences engagement through increasing mental health lit- resulting from their illness, and expectations eracy and decreasing stigma among family mem- about what types of treatment would be appropri- bers (López et al., 2009), who often play a role in ate for them (Benish et al., 2011; Bhui, Rudell, & facilitating mental health care for their relatives Priebe, 2006; Rudell, Bhui, & Priebe, 2009). It is with mental illness (Urdaneta, Saldaña, & not uncommon for Latinos to experience greater Winkler, 1995). somatic symptoms associated with mental illness Finally, providers may consider the potential (Lewis-Fernandez, Das, Alfonso, Weissman, & need for a more flexible attendance policy when Olfson, 2005; Piña & Silverman, 2004; Varela treating Latinx clients. It is not uncommon for et al., 2004), see mental illness as being caused Latinos to work longer hours (Wells et al., 2013), by primarily psychosocial (Caplan et al., 2011; have lower levels of full-time employment, make Jimenez, Bartels, Cardenas, Dhaliwal, & Alegría, less money, and have poorer benefits packages 2012) or religious/supernatural (Caplan et al., 172 A. J. Bridges and A. R. Dueweke

2011) forces, worry their mental illness will whether a particular metaphor, for example, result in consequences such as social shame or makes sense to the client, they should ask. rejection (Hirai, Vernon, Popan, & Clum, 2015; Similarly, it could be a useful exercise for thera- Interian, Martinez, Guarnaccia, Vega, & Escobar, pists to first explain a particular treatment con- 2007), and express concerns about the use of psy- cept, then work collaboratively with the client to chotropic medications (Cabassa et al., 2007; create a metaphor for that concept that feels rel- Cooper et al., 2003). evant (Bernal, Bonilla, & Bellido, 1995). For instance, when creating a progressive muscle As stated above, it is important to elicit the relaxation exercise with children, rather than ask- client’s explanatory model during intake and ing the child to pretend to be uncooked spaghetti throughout the initial phases of treatment. (tense up the body), then cooked spaghetti Starting treatment with an expressed understand- (loosen the body muscles), the therapist and child ing and respect for the client’s framing of their opted to talk about being a hard shell tortilla and problems allows the therapist greater flexibility a soft shell tortilla (de Arellano, 2012, personal to build alternative explanatory model later in communication). treatment (Benish et al., 2011). Ultimately, the Finally, therapists working with Latinx clients therapist and client can work together to co- must be willing to be flexible and devote time to create a new, culturally congruent illness expla- addressing the unique therapeutic needs that may nation that incorporates both clinical science and arise from living as a Latinx in a predominantly the client’s initial framing of their illness White culture. For example, addressing immigra- (Wampold, 2007). During the process of collab- tion stressors specifically could lead to a decrease oratively constructing a new framework and in symptoms associated with this domain in ways treatment rationale, therapists working with that would not occur with strict adherence to a Latinx clients would be wise to use relevant cul- manualized treatment (Barrera & Castro, 2006). tural values to their advantage, rather than chal- We have worked with countless Latinx clients lenging or fighting against them (Hays,2009 ). experiencing depression, anxiety, and worry as a For example, if a client has expressed a strong result of increased Immigration and Customs belief in respeto, a cultural value emphasizing Enforcement (ICE) raids in the area. While man- obedience to authority and maintenance of har- ualized cognitive-behavioral treatments typically mony (Calzada, Fernandez, & Cortes, 2010; include a focus on the client’s thoughts and Gonzales-Ramos, Zayas, & Cohen, 1998), behaviors that may be maladaptive, these cases encouraging assertiveness skills may not be a involved serious mental health symptoms that welcomed therapeutic activity, particularly if a followed from an external situation that was, in therapist is asking the client to practice assertive- actuality, extremely stressful and upsetting. In ness skills within a family context (e.g., standing many of these cases, we devoted therapy sessions up to unfair treatment by a parent). Rather than to validation of the client’s concerns and active questioning the utility or validity of respeto as a problem-solving (e.g., education about legal cultural belief, the therapist could instead frame rights, facilitating connections with local immi- assertive communication as a respectful avenue gration clinics, creating a plan in case of removal for solving problems, because it honors the rights procedures) rather than debating the validity of and beliefs of all people involved in a situation the client’s fears. (Bernal & Saez-Santiago, 2005). While Latinx clients may be faced with dis- Beyond incorporation of the client’s illness tinct risk factors (e.g., discrimination, low social myth and relevant cultural values into treatment, standing, cultural intergenerational conflict, therapists working with Latinx clients should unemployment) compared to non-Latinx White also consider adapting the metaphors and case clients, they may also benefit from unique protec- examples used throughout treatment to make tive factors (e.g., strong family support networks, them more relevant. If a therapist is unsure about religious involvement). The interplay between 12 Behavioral Health Services in Latinos 173 cultural context and the distinct set of risk and identity weaves into other identities to impact resilience factors Latinx clients experience is cru- that person’s lived experiences, and to let this cial to consider when reflecting on how and when guide their approach to therapy. 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Frances R. Gonzalez

Demographics Psychological Distress

According to a national survey, in the USA an Lesbian, gay, bisexual, and transgender (LGBT) estimated 4.5% (roughly 11,343,000 people) of individuals encounter a range of stressors the adult population identifies as lesbian, gay, throughout their lifetime (Mongelli et al., 2019). bisexual, or transgender (LGBT; The William’s With a history of being a marginalized minority institute, 2019). The LGBT community has group, various mental health disparities have grown significantly and continues to grow. In been associated with these stressors. Compared 2012 the LGBT population was estimated at to heterosexuals the LGBT community reports 3.5% while in 2016 it was estimated to be 4.1% higher prevalence rates of anxiety, depression, (Newport, 2018). The largest birth cohort that trauma, substance abuse, and suicide (Mongelli contributed to the increase in the LBGT popula- et al., 2019). tion are millennials, individuals born between 1980 and 1999 (Newport, 2018). A 2013 survey reported that 1.7% of adults identified as gay or Anxiety and Depression lesbian, 0.07 reported identified as bisexual (Ward, Dahlhamer, Galinsky, & Joestl, 2014), While the lifetime prevalence of depression while roughly 700,000 individuals (0.03% of the ranges from 20% to 25% in women and 7% to US population) identify as transgender (Flores, 12% in men (Wang et al., 2017), among the Herman, Gates, & Brown, 2016). The majority of LGBT community the prevalence rates of depres- those in the LGBT community are likely to iden- sion are higher. Barefoot, Warren, and Smalley tify as Hispanic, female, have an income of less (2017) conducted a national survey and reported than $36,000, and have the mean age of 37 years that 43% of transgender females, 35% of trans- (Newport, 2018). Although these statistics are gender males, 31% of bisexual females, 24% of available, the literature is lacking updated infor- gay men, 22% of bisexual, and 16% of lesbians mation regarding how many LGBT individuals met criteria for depression. For anxiety, an esti- identify as lesbian, gay, and bisexual. mated 10% of US adults had any anxiety disorder in the past year (Bandelow & Michaelis, 2015) while among the LGBT community 40% of transgender females, 32% of transgender males, F. R. Gonzalez (*) 29% bisexual females, 27% of bisexual males, Department of Psychology, University of Nevada, 19% of gay males, and 18% of lesbians met Reno, Reno, NV, USA

criteria for anxiety (findings from a national sur- Exposure to the various forms of violence vey; Barefoot et al., 2017). may account for why post-traumatic stress disorder (PTSD) is more prevalent among the LGBT community than non-sexual minorities (Roberts, Trauma and Post-traumatic Stress Austin, Corliss, Vandermorris, & Koenen, 2010; Disorder Wawrzyniak & Sabbag, 2018). The LGB community is 1.6–3.9 times more at risk of PTSD Lifetime prevalence of victimization among the (Roberts, Rosario, Corliss, Koenen, & Austin, LGBT community has been reported to be 2012), while for the transgender community higher than that of non-LGBT individuals PTSD has a prevalence rate of 7% (Reisner et al., (Balsam, Rothblum, & Beauchaine, 2005). In 2016; Wawrzyniak & Sabbag, 2018). Among one study by Balsam, Rothblum, and LGBT veterans, PTSD is also reported at higher Beauchaine (2005), the lifetime victimization rates than non-sexual minorities (Brown & Jones, of LGB individuals was explored. LGB partici- 2016; Cochran, Balsam, Flentje, Malte, & pants reported more incidents of childhood and Simpson, 2013; Wawrzyniak & Sabbag, 2018). adulthood victimization than heterosexual participants. Bisexual men and women were more likely than gay men to report an incident of Substance Abuse nonintercourse sexual coercion and rape (Balsam et al., 2005). About 37% of partici- According to the results of a 2015 survey, an esti- pants reported experiencing physical abuse mated 39% of LGB adults reported using an (e.g., grabbed, punched, choked, stabbed, or illicit drug within the year prior to the survey, shot) since the age of 13. Participants reported more than twice as likely than heterosexual adults a lifetime average of four incidents of physical (17%, Medley et al., 2016). For marijuana use it attacks with half of these incidents being linked was reported that 30% of LGB individuals used to participants gender identity or expression within the year prior to the survey compared to (Balsam et al., 2005). 13% of heterosexual adults (Medley et al., 2016). Additionally, the LGBT community experi- In regard to prescription pain relievers, 10% of ences hate crimes due to their sexual orientation LGB adults used within the year prior to the sur- and gender identity. The Federal Bureau of vey compared to 4.5% of heterosexual adults Investigation’s (FBI) Uniform Crime Reporting (Medley et al., 2016). In a survey conducted in Program (UCR) reported that in 2017, 5125 2013 35% of LGB adults aged 18–64, who iden- adults were victims of hate crimes. For the LGB tified as gay or lesbian, 42% of bisexual adults, community 15.8% (1338) were targeted because and 26% of heterosexuals reported past-year of bias against sexual orientation and 1.6% binge drinking (five or more drinks on a single (132) were victims of gender-identity bias. occasion; Ward et al., 2014). Specifically, we see More specifically, 25% were victims of anti- that bisexual men reported the most binge drink- LGBT bias, 58% were victims of anti-gay bias, ing (52%; Ward et al., 2014). 12% were victims of anti-lesbian bias, and 2% According to a 2015 survey, about 4% of were victims of anti-bisexual bias. For individu- transgender adults used illicit drugs within the als who identify as transgender 119 were vic- month prior to the survey, while 29% had reported tims of anti-transgender bias and 13 were using illicit drugs in their lifetime (Ward et al., victims of anti-gender non-conforming bias. 2014). An estimated 7% of transgender adults Interestingly only two-thirds of hate crimes are used prescription drugs that were not prescribed reported, therefore the rates of incidents may be to them or used them as not prescribed (Ward higher for the victims of crime particularly those et al., 2014). Among transgender adults about in the LGBT community (Sandholtz, Langton, 25% reported using marijuana within the past & Planty, 2013). month of when the survey was taken (Ward et al., 13 Cultural Considerations in Behavioral Health Service Delivery with LGBT Populations 179

2014). Finally, about 27% of transgender adults LGBT community predict their mental health reported binge drinking within the month prior to outcomes. For example, among individuals who the survey (Ward et al., 2014). identified as LGBT stigma (internalized, enacted, and anticipated) was associated with increased depression scores (Marsack & Stephenson, Suicide 2017). Specifically, individuals who identified as bisexual or queer reported higher stigma and A systematic review on the lifetime prevalence of depression scores than gay and lesbians’ partici- suicide attempts among LGB adults by Hottes, pants (Marsack & Stephenson, 2017). Minority Bogaert, Rhodes, Brennan, and Gesink (2016) stress has also been linked to increased suicidal- reported that the lifetime prevalence of suicide ity thoughts and attempts among the LGBT com- attempts among individuals who identify as LGB munity, specifically when experiencing was about 20% while for the general population internalized homophobia (Lea, de Wit, & (non-sexual minorities) it was reported to be Reynolds, 2014) and transphobia (Perez-Brumer, around 11%. A literature review performed by Hatzenbuehler, Oldenburg, & Bockting, 2015; Virupaksha, Muralidhar, and Ramakrishna Timmins, Rimes, & Rahman, 2017). Additionally, (2016) found that the worldwide lifetime preva- we see similar trends with alcohol consumption. lence of suicide attempts for the transgender pop- Heaving drinking days are reported more often ulation to range from 32% to 50%. In the USA among gay men who experienced internalized the lifetime prevalence rates of suicide attempts heterosexism (Kuerbis et al., 2017). Finally, among individuals who identify as transgender another group within the LGBT community that were reported at 40% (National Center for experiences minority stress are individuals who Transgender Equality, 2017). For LGBT commu- are HIV positive. Rendina et al. (2017), exam- nity aged 10–24, suicide is one of the leading ined HIV-related stressors among gay and bisex- causes of death (Center for Disease and ual men. Internalized stigma was significantly Prevention, 2010). Currently, there are limited associated with negative mental health and sexual resources that are tracking suicide by sexual ori- behavior outcomes. A path analyses revealed that entation for the adult population making it chal- emotion dysregulation mediated internalized lenging to find current prevalence rates for LGBT stigma on symptoms of depression/anxiety adults. (Rendina et al., 2017). The authors from this study implicate that cognitive restructuring and emotion regulation may be particularly useful in Minority Stress targeting the negative self-schemas and difficulty with emotion regulation problems reported by Meyer (2003) created a model that recognizes the participants in the study. that marginalized groups, such as the LGBT community, experience stressors unique to their group in the form of prejudice and discrimina- Summary tion. Meyer theorized that such stressors significantly impact the mental health of the LGBT The LGBT community experiences high levels of community. Such stressors include experiencing anxiety, depression, trauma, substance abuse, and prejudice events, expectations of rejection, inter- suicidal ideation. There are notable prevalence nalized stigma, and internalized homophobia differences among each sexual minority sub- (Meyer & Frost, 2013). A systematic review by group, for example, individuals who identify as Mongelli et al. (2019) examined the relationship transgender experience higher rates of psycho- between minority stress and mental health among logical distress than other sexual minority sub- LGBT population. The findings from the review group. Minority stress has been linked to indicate that the stressors experienced by the increased psychological distress among sexual 180 F. R. Gonzalez minorities, specifically prejudice and discrimina- cesses (i.e., rejection sensitivity, internalized tion. Several evidence-based treatments have homophobia, concealment) and universal risk been adapted to address the specific needs of the factors (i.e., hopelessness, rumination, social iso- LGBT community, including addressing minor- lation, unassertiveness). The Unified Protocol ity stress. (UP) promotes changes through modules that focus on motivation enhancement, exposure, cognitive restructuring, mindfulness, self- Evidence-Based Treatments monitoring techniques, and techniques of behav- for Mental Health Among LGBT ior change across psychosocial problems and Clients disorders (Barlow et al., 2017). Pachankis et al. (2015) specifically adapted There are various evidence-based treatments that the intervention to help participants identify are recommended to be used with the LGBT minority stress experiences; track cognitive, community. One treatment that will be briefly affective, and behavioral reactions to minority discussed is cognitive behavioral therapy for stress, address avoidance reactions (i.e., sub- LGB. stance use and condomless anal sex), attribute distress to minority stress rather than to personal failure; and assertiveness training for coping with Cognitive Behavioral Therapy (CBT) minority stress in safe situations. The Unified Protocol Modules were described in detail in Cognitive behavior therapy has been effective in Pachankis (2014) and briefly described below as reducing psychological distress among a range of in Pachankis et al. (2015): populations with various disorders (Coull & Morris, 2011). CBT is effective in addressing • Session 1 focused on discussing primary men- presenting maladaptive behaviors and motivates tal, behavioral, and sexual health issues; build- clients to cope with adverse circumstances by ing motivation to address those issues; and promoting coping self-efficacy (Pachankis, reviewing participants’ unique strengths as Hatzenbuehler, Rendina, Safren, & Parsons, gay or bisexual men. 2015). CBT encourages the development of • Session 2 reviewed the impact of minority adaptive cognitive, affective, and behavioral stress on health, specific manifestations of stress responses (Pachankis et al., 2015). CBT minority stress, and current coping strategies. can be used to improve psychological distress • Session 3 raised awareness of the emotional among the LGBT population since it can target impact of early and ongoing forms of minority cognitive, affective, and behavioral minority stress. stress processes (Balsam, Martell, & Safren, • Session 4 raised awareness of the behavioral 2006; Pachankis, 2014; Pachankis et al., 2015). impact of minority stress and taught mindful, CBT has been adapted to address stressors that present-focused reactions to minority stress. the LGB community may face in addition to • Session 5 raised awareness of the cognitive addressing psychological distress. impact of minority stress and posed cognitive Pachankis et al. (2015) created a study to restructuring activities. assess the efficacy of a CBT adaptation to • Session 6 engaged participants in a review of improve young gay and bisexual men’s mental the impact of emotions on mental, behavioral, health. They adapted the Unified Protocol for and sexual health and personal emotion avoid- Transdiagnostic Treatment of Emotional ance tendencies driven by minority stress. Disorders (Unified Protocol; Barlow et al., 2017) • Session 7 focused on the impact of minority intervention to target both minority stress pro- stress on behavioral avoidance with a focus on 13 Cultural Considerations in Behavioral Health Service Delivery with LGBT Populations 181

creating an emotional and behavioral avoid- of HIV/AIDS on the lives of lesbian, gay, and ance hierarchy. bisexual individuals and communities (Guidelines • Session 8 engaged participants in behavioral 16), and encouraging psychologists to consider experiments in which previously avoided the impact of socioeconomic status on the psy- experiences were gradually confronted. chological well-being of lesbian, gay, and bisex- • Session 9 continued the graduated behavioral ual clients (Guideline 18). The entire list of experiments with a focus on assertiveness guidelines can be found at: https://www.apa.org/ training as a skill for coping with minority pubs/journals/features/amp-a0024659.pdf. stress. Although these guidelines are helpful, they are • Session 10 reviewed new cognitive, affective, not as detailed as the clinical principles and tech- and behavioral coping strategies and their niques suggested by Pachankis (2014). The prin- application to future minority stress experi- ciples include: ences (Pachankis, 2014). Therapists assigned homework between-session homework after • Normalize the adverse impact of minority sessions to promote skill generalization. stress. • Facilitate emotion awareness, regulation, and The adapted UP protocol above was compared acceptance. to a waitlist condition. The participants in the UP • Reduce avoidance. condition reported reduced depressive symp- • Empower assertive communication. toms, alcohol use problems, sexual compulsivity, • Restructure minority stress cognitions. and condomless anal sex with casual partners, • Validate sexual minority individuals’ unique and improved condom use self-efficacy. The UP strengths. did not significantly reduce the cognitive, affec- • Build supportive relationships. tive, or behavioral minority stress processes or • Affirm healthy, rewarding expressions of universal mental health risk factors. Although sexuality. other sexual minorities were excluded from the study, the intervention addresses material that These principles assist therapists and psychol- can be used with lesbian, bisexual women, and ogists to better work with clients who are LGB. A transgender men and women. As noted by Weir more detailed list can be found in Pachankis and Piquette (2018) the transgender community (2014). The guidelines from the APA (2012) and experience violence, discrimination, along with the principles by Pachankis (2014) are very other stressors that impact psychological well- important but have been limited to only being. Therefore, exploring treatments that aim at LGB. Weir and Piquette (2018) describe some targeting minority stress in addition to psycho- considerations for therapists to take when work- logical distress may be beneficial for individuals ing with transgender clients. The most important who identify as transgender especially since they consideration is being supportive and knowl- also experience hopelessness and rumination edgeable about the transgender community. A which is targeted by the Unified Protocol. therapist who has knowledge of sexual orientation, issues faced by LGBT individuals, community resources, as well as the barriers that may be Guidelines for Working present with a school or larger community can be for with LGBT Clients a powerful support (Weir & Piquette, 2018). Advocating for transgender individuals, using The American Psychological Association (2012) transgender affirmative language, awareness and has 20 guidelines for working with LGB clients. discussion of historical marginalization, pathol- The guidelines cover an array of important issues ogy descriptions within the assessment and diag- including therapists understanding the effects of nosis stage, and promotion of social justice are stigma (Guideline 1), understanding the impact other forms of support a therapist can provide 182 F. R. Gonzalez

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Canadian ences: A longitudinal examination of mental health Psychology/Psychologie Canadienne, 59(3), 252–261. and sexual risk behavior. Annals of Behavioral https://doi.org/10.1037/cap0000129 Behavioral Health and Muslim Clients: Considerations 14 for Achieving Positive Outcomes

Cory E. Stanton

Introduction is a topic in psychological theory that is hotly debated, with current models suggesting that the Islam is currently the world’s second largest reli- characteristics of individual immigrants, the traits gion, with approximately 1.6 billion followers of their originating group, and tendencies of the worldwide, and is expected to be nearly equal in host society all interact in complex ways number of followers to Christianity by 2050 (Pew (Khawaja, 2016). Other recent work suggests that Research Center, 2015). While the Asia-Pacific acculturation is not a uniform or “whole cloth” region is expected to remain the home of most of process; positive and negative effects can be the world’s Muslim population, Muslim immi- observed simultaneously or sequentially, and gration to Europe and North America is steadily instances of acculturative processes may be increasing (Hackett, 2016; Lipka, 2015). The viewed continuously or discretely (Ali, 2008; Al USA admitted 38,901 Muslim refugees in 2016 Wekhian, 2016; Khawaja, 2016). Muslim immi- (note that the USA does not track the religion of grants, especially in the post-9/11 era, experience other legal immigrants; Connor, 2016), and while unique integration and acculturation challenges. Muslims are approximately 1% of the US popu- Muslims face prejudice and discrimination in lation at present, they are expected to be 2.1% of Western nations in which they are a minority the US population by 2050 (Lipka, 2015). (Ansari, 2004; Panagopoulos, 2006; Sheridan & Muslim immigration to Western countries is Gillett, 2005; Zolberg & Woon, 1999). The effects driven by demands for labor, as well as in part by of discrimination complicate the already difficult the desires of immigrants for better economic process of Muslims acculturating to new societies conditions and financial security (Kamali & that they find themselves living in. Given recent Abdullah, 2015). events, how are Muslim immigrants affected by Despite the expected growth of Islam and these processes? How is the experience of US increase in Muslim immigration to Western born Muslims similar or different? What should nations during the next several decades, important the behavioral health service provider know about aspects of Muslim acculturation are not well working with Muslims as clients? understood (Khawaja, 2016). Acculturation itself The goal of this chapter is to review the literature regarding behavioral health service delivery for Muslim clients (with a focus on psychother- C. E. Stanton (*) apy services), as well as orient the reader to sup- Department of Psychology, University of Nevada, Reno, Reno, NV, USA plemental knowledge that is intended to increase e-mail: [email protected] cultural competency. This will include

information about behavioral health needs rele- persons, and (3) deference to male familial fig- vant to Muslim clients. It will also briefly define ures when making treatment relevant decisions and review acculturation and the related construct (Hammoud, White, & Fetters, 2005; Ibrahim & of acculturative stress. In addition, this chapter Dykeman, 2011; Simpson & Carter, 2008). For will examine a key topic relevant to Muslim inte- example, handshakes or other forms of physical gration with the West: the issue of Islamic juris- contact between female Muslim clients and male prudence and how it directly relates to care providers are discouraged (for more guid- acculturation and acculturative stress. Given the ance and recommendations, see Hammoud et al., potential for misunderstanding regarding the 2005). When domestic violence concerns are nature of Islamic jurisprudence, the section will salient, providers may benefit from reviewing emphasize the nuance and diversity of opinion in how Islam and other religions can be misinter- the Islamic world on this topic. Recommendations preted in an attempt to justify violence against for conducting psychotherapy and other behav- women (Jayasundara, Nedegaard, Flanagan, ioral health interventions with Muslim clients Phillips, & Weeks, 2017). will be discussed. Note that because of space considerations, this chapter does not include an introduction to the basic tenets of Islam. The Effects of Acculturative Stress reader with little background on Islam is referred on Muslim Mental Health to other literature to establish some familiarity with its basic features as a religion (e.g., Ali, Liu, Acculturation can be defined as the process of & Humedian, 2004) bidirectional change that takes place when two different ethnic and/or cultural groups encounter one another, and change occurs as a result Current Mental Healthcare Needs (Bourhis, Moise, Perreault, & Senecal, 1997; of Muslim Clients Redfield, Linton, & Herskovits, 1936). Acculturation expectations vary for both various Robust epidemiological data about the preva- ingroup and outgroup populations. For example, lence of mental and behavioral health problems it is possible to sort the acculturation expecta- in the US Muslim population is scarce, at best. tions of ingroup members into categories such as Common mental health problems encountered in integrationism, segregationism, and assimilation- treatment with US Muslims include marital and ism (Kunst, Sadeghi, Tahir, Sam, & Thomsen, relationship problems, issues related to religious 2015). Segregationism is the stance that minori- taboos (drug and alcohol use, sexual activity out- ties should keep their heritage culture intact, but side of heterosexual marriage), depression, and they should also be isolated from the society at anxiety (Arfken & Ahmed, 2016; Rassool, 2015) large. Assimilationism expects minority mem- Muslim women experience unique needs as a bers to embrace the host or national culture while result of gender role expectations within cultures also identifying less with and eventually aban- that predominantly endorse Islam. Rules regard- doning their heritage culture. Integrationism ing opposite-sex interactions, as well as the gen- argues that minorities can and should adopt the eral level of patriarchy common in Muslim national culture, while also being connected to societies, are two areas where Western trained their heritage culture. Integrationism is the only clinicians may stumble (Ibrahim & Dykeman, stance that requires the majority society to change 2011). Studies have identified multiple factors in some way, for accommodating new members. that influence Muslim women’s interaction with When thinking about minority group members healthcare providers: (1) the perceived power dif- (such as Muslims immigrating to or residing in ferential between client and provider, (2) reli- the West), Berry (1980) suggests that these indi- gious proscriptions regarding gender and viduals are trying to balance the desire to main- mixed-gender interactions between non-related tain affiliation with their heritage culture, while 14 Service Delivery with Muslim Clients 187 also growing to appreciate the national culture with the host culture in the opposite direction they now live alongside. Recent research sup- (Goforth, Oka, Leong, & Denis, 2014). Other ports the notion that acculturation is better under- research shows a link between perceived discrim- stood as a bidirectional process rather than a ination and subclinical paranoia, but not anxiety, unidimensional one, with implications for per- with differences across subgroups (Rippy & sonality, identity development, and other psycho- Newman, 2006). social factors (Ryder, Alden, & Paulhus, 2000). The presence of hostile attitudes on the part of Successful acculturation is a set of psychological majority group members seems to predict diffi- processes that enable integration (Berry, 2001, culty acculturating for US Muslim immigrants 2008; but for readers interested in the possible (Kunst et al., 2015). In addition, how mental limitations and an expansion of Berry’s ideas; see health stigma interacts with aspects of Muslim Ward, 2008) identity is poorly understood, and more research It is well documented that acculturative stress is needed (Ciftci, Jones, & Corrigan, 2012). What impacts the well-being of Muslim immigrants to we do know is that in part because of stigma, the USA and other Western nations. In the USA, Muslim mental health problems are sometimes barriers to successful acculturation include cul- expressed somatically or as physical symptoms tural and religious differences, differing views on (Fakhr El-Islam, 2008). In addition, particularly gender, discrimination, the portrayal of Muslims in the USA, the impact of racial discrimination in popular media, and differences in moral and on the mental health of minorities is understood ethical values (Al Wekhian, 2016). Driscoll and for several racial groups, including African- Wierzbicki (2012) have found that religiousness, Americans, Hispanics, Asian-Americans, Jews, not acculturation, predicts lower levels of depres- and others. However, there is less research that sion in Pakistani and Palestinian Muslims in the specifically examines the effects of discrimina- USA, though acculturation did predict lower tion on Muslims as a religious group (Rippy & interpersonal causes of depression. This suggests Newman, 2006). One recent study with a national that different etiological mechanisms may be at sample of Muslims did conclude that experienc- play that differentially interact with accultura- ing discrimination was predictive of depression tion, an area that requires further study. but not of substance abuse (Hodge, Zidan, & Depression in older Muslim immigrants is par- Husain, 2015). tially predicted by identifying with heritage cul- There is also a need to further understand how ture as opposed to American culture (Abu-Bader, the racial or ethnic backgrounds of Muslims (i.e., Tirmazi, & Ross-Sheriff, 2011). Higher levels of India, Indonesia, Nigeria, Bosnia, Caucasian, acculturative stress predict lower levels of life etc.) intersect with other aspects of identity in the satisfaction and higher levels of psychological context of prejudice and discrimination. For symptoms for Muslims in New Zealand, while example, Ajrouch and Kusow (2007) found that, interestingly, religious based coping strategies in an ethnographic interview study, Lebanese and did not affect levels of symptoms (Adam & Ward, Somali Muslim immigrants use different strate- 2016). Acculturative stress predicts decreased gies in integrating with Western countries. Both life satisfaction and greater behavioral problems groups seek to make their religious identities for young Muslim adults in both New Zealand salient. However, Somali immigrants experience and the UK; family obligations can increase “othering” processes with both their race and adaptation but can interact with acculturative religion, while Lebanese immigrants do not stress to predict poorer adaptation as well (Stuart, experience this about their race. There is addi- Ward, & Robinson, 2016). Muslim immigrant tional literature available on the nuances of how adolescents who are younger, more religious, and Islamic and racial identities intersect and relate to have spent less time in the USA are more likely acculturation, which is recommended reading for to endorse strong identification with their heri- providers who see a diversity of ethnic identities tage culture, with no corresponding association in their settings (e.g., Archer, 2001; Meer, 2008; 188 C. E. Stanton

Sirin & Fine, 2007). What is clear is that accul- they live, Muslims around the world vary consid- turation interacts with a variety of other psycho- erably in their beliefs that Sharia should be codi- logical and sociological processes as a predictor fied into their respective nation’s laws; whether of stress and mental well-being. Behavioral Islam is an official state religion seems to be a health providers can avoid the pitfalls of confus- key variable (Pew Research Center, 2013). Like ing cultural, ethnic, and religious identities by other religious systems, Islamic law is frequently being mindful of the intersectionality of Muslim relevant to medical ethics and decision-making client identities. Indeed, though many Muslim by both Muslim physicians and Muslim patients Americans are Arabs, more Arab Americans are (Butt, 2012; Hatami, Hatami, & Hatami, 2013; Christians than Muslims (Hammoud et al., 2005). Shapiro, 2013; Varley, 2012; Zainuddin & As previous research has shown, acculturation Mahdy, 2017). It is suggested that behavioral is a key process for any immigrant population health providers that work in areas allied with moving to a nation with a different culture. Skills medical practice, such as hospital settings or inte- for living in the host society, as well as having the grated care, review foundational information on freedom to maintain heritage traditions, are Islamic bioethics in order to facilitate better directly related to decreased distress among understanding and cultural competency when Muslim immigrants (Fassaert et al., 2011). engaging with Muslim clients, especially in a Therefore, it is important to have a clear under- medical decision-making context (e.g., Chamsi- standing of the psychological processes at play Pasha & Albar, 2013; Daar & Khitamy, 2001). during acculturation. Muslim immigrants, like Muslim individuals tend to believe that, unless others, experience varying degrees of accultura- they live in societies in which Islam is the state tion success. Examining how Muslim immigrants religion, living in a democracy generally entails have adapted one important aspect of their cul- living with secular legal systems and view these ture to Western societies demonstrates the poten- systems as enablers of religious pluralism, which tial for immigrant communities to integrate is ultimately good for everyone (Pew Research successfully. For native born Muslims in Western Center, 2013). For Muslims, the notion of arbi- societies, this aspect is still both an important trating legal disputes in the context of Sharia facet of cultural heritage, and a potential source allows them to retain linkages to their heritage of misunderstanding. culture even as they seek to integrate successfully into non-Muslim countries. For many Western cultures, the subject can be a touchy one. Islamic Jurisprudence Korteweg (2008) describes how the issue of Sharia council arbitration prompted a vigorous Cultural and religious traditions develop legal debate in Ontario, Canada. Korteweg illustrates systems and legal philosophies, and such a his- how notions of agency are embedded within cul- tory is also richly present in Islam. Islamic juris- tures and are directly related to how one would prudence refers to the application of Islam to the conceptualize Sharia councils as either encroach- study of laws, legal codes, and legal theories. ments on the autonomy of Muslim women, or as This not only includes the Qur’an itself, but also culturally relevant aspects of Muslim identities the history of social and legal customs in the for both men and women. As previously dis- wider Islamic community (Sunnah) as well as the cussed, the degree to which Muslims are able to consensus of Islamic legal scholars (Ijma), relate to their heritage culture is directly related among other components (Kamāli, 2003). to their well-being. When it comes to the various Stereotypes about the encroachment of Sharia dimensions by which Muslim immigrants suc- law into US society is linked to pronounced, irra- cessfully interface with host societies, how all the tional fear of Muslims (Fallon, 2013). Contrary parties deal with the issue of Sharia is directly to stereotypes about Muslims and their desire for related to the extent by which Muslims experi- Sharia to be the dominant legal system where ence prejudice and discrimination, and the extent 14 Service Delivery with Muslim Clients 189 by which majority group members experience macy of religious organizations as compared to unfounded paranoia and fear (Khan, 2012). civil law. Judges in England are willing to defer Specific to the USA, it appears that fear of to the decisions of Sharia councils in England on Muslims is at least in part due to the political and matters of marriage, so long as the council’s legal legislative activities of organizations opposed to process and outcome do not conflict with English a “Sharia takeover” (Uddin & Pantzer, 2011). precedent (Bowen, 2011). Thus, mediations by Thus, it is imperative that any discussion on how Sharia councils in England enjoy a status of legit- acculturation is successful for Muslim immi- imacy not seen elsewhere. In the USA as well as grants, or how natural born Muslim citizens France, the situation is quite different. While in interact with Western societies generally, includes England marriage is largely an individualized a discussion of Sharia and the function it serves and contractual matter, the French treat marriage Muslims in daily life. Understanding these func- and family as important aspects of public life and tions is relevant for providing effective behav- society. The structure of French civic life and its ioral health services. legal institutions do not permit religious councils Bowen (2011) provides a useful analysis of any formal role in resolving matters such as mar- how Muslim communities in France, the U.K., riage (Bowen, 2011). Imams in France encourage and the USA apply the principles of Islamic juris- couples to first get married in civil court before prudence within the context of their host societies having an Islamic marriage, as imams who marry to the topic of women seeking divorces. Divorce Muslims who are not civilly married are guilty of in Islamic law is complicated because men and a crime in the French system (Bowen, 2011). In women have different powers per most schools of matters of divorce, imams frequently council Islamic jurisprudence. A man can annul his mar- women to seek civil divorce and mediation, and riage and release his wife from the obligation to often find themselves assuring Muslim women pay a dower, but a woman can either ask her hus- that they are not disrespecting their faith by doing band to divorce her or ask a judge to dissolve the so (Bowen, 2011). In the USA, court systems rely marriage if her husband has failed to perform his on civil law (as in France), but Sharia councils duties (Bowen, 2011). Most Muslims live in are still permitted (as in England). As opposed to areas with modern legal systems that more councils in England, where multiple schools of closely resemble either British common law or Islamic jurisprudence exist, only one school is French civil law (indeed, civil and common law common, and is predominantly endorsed by are the two most widespread legal traditions South Asian Muslims. These councils (often lone around the world; Merryman & Pérez-Perdomo, imams) can be approved by US courts to grant 2007). Civil law resembles the legal system of marriages and deal with dowers as issues of pre- the USA: ordinances and statutes define with nuptial agreements, but this varies state to state. actions are illegal and prescribe penalties for American courts are more wary than English engaging in those acts. Common law relies ones to refer to religion or religious precedent; as almost entirely on case precedent and judicial a result, imams in the USA have sought guidance prerogative in resolving legal issues; while judges from US judges on how to frame or word dower in civil law systems draw upon case precedent in arrangements such that they resemble contracts the context of applying codified law, precedent is recognized in the American legal system (Bowen, the entirety of common law systems (Merryman 2011). These three different legal realities for & Pérez-Perdomo, 2007). Muslim immigrants are arguably reflections of More so than other nations in Europe and the the little discussed school known as “jurispru- USA, Muslims in the U.K. tend to live in clus- dence of Muslim minorities” (Kamali & tered neighborhoods composed almost entirely of Abdullah, 2015; Kazemipur, 2016). The goal of other Muslims; such neighborhoods also cluster this school is to ensure that Muslim minorities by nation of origin (Bowen, 2011). English com- have a coherent system with which to interpret mon law also provides more room for legal legiti- Islamic law, while also being sensitive to the 190 C. E. Stanton

reality that traditional Islamic jurisprudence may predict such success? These issues suggest prom- not be compatible with non-Muslim societies. ising lines of inquiry for social, cultural, and For example, Kamali and Abdullah (2015) state political psychologists. Conversely, behavioral that the jurisprudence of Muslim minorities spe- health providers should orient to how particular cifically calls on Muslims to both preserve their clients view the role of Islamic jurisprudence in religious identities, but also to act in good faith their daily lives. Providers should focus on ask- and be responsible citizens of the countries they ing and understanding the perspective of the cli- live in. It suggests a balance between literal inter- ent that they see, as well as the practices of the pretations of Sharia, as well as contextual consid- family system that the client is associated with. erations and the overall aspirational goals of the Muslim individuals and their families vary the religious life. There is at present a continued degree to which they incorporate Islamic judicial debate as to how much comity, or acknowledge- practice into their culture. Identifying the general ment of foreign precedent, US courts should stance that the family system takes on matters grant to Islamic legal precedent (Fallon, 2013). related to Sharia and Islamic law may be useful The nonpartisan Council on Foreign Relations, for anticipating or resolving religious conflicts. a US think tank, provides another interpretation For more information on working with Muslim of how Muslims view the relationship between couple and family dynamics, see Springer, Sharia and secular legal systems in society Abbott, and Reisbig (2009). (Johnson & Sergie, 2014). Specifically, they suggest that Muslims tend to prefer one of three different arrangements: dual legal system (in which Taking a Broader Social Muslims may choose to take family law and Perspective: Contact Theory financial disputes to Sharia councils), religiously and Intergroup Contact influenced governments (typically where Islam is the official state religion), and complete secular As has been discussed thus far, Muslim residents governments (though these are less common). in the USA face prejudice and discrimination. Muslims still tend to prefer democratic forms of Behavioral health providers do not see individual government over strong, authoritative systems Muslim clients separate from their context: cli- (Johnson & Sergie, 2014). ents seek services as members of families and The imams and their unique strategies dis- communities. These communities, in non- cussed in Bowen (2011) demonstrate a kind of Muslim majority societies, face challenges at the political acculturation, balancing the values of group level of analysis related to negative inter- the immigrant group with the values of the group relations. In order to relate effectively to broader society. Political acculturation refers to clients from these backgrounds, providers are the degree to which immigrants advocate for likely to benefit from a broad perspective that their ingroup as well as the broader societal inter- incorporates these group level processes into est. Whether immigrant political activity is per- their conceptualization of Muslim clients and the ceived as valuing ingroup interests and/or valuing problems that they report. Indeed, such a multi- societal interests yields the following categories: level view comports with the actual consider- integration, assimilation, separation, and margin- ations some Muslim individuals weigh when alization (for more information, see Hindriks, deciding whether or not to seek services (e.g., Verkuyten, & Coenders, 2015). Positive accul- Alhomaizi et al., 2017). turation outcomes depend in part on the ability of It is necessary to frame a discussion around Muslim minorities and majority groups to come the social psychology of Muslim acculturation to consensus on legal and other issues (Kazemipur, and intergroup relations in the context of a suit- 2016). How do these imams find success and sus- able theory, one with strong theoretical and tain it in these ways? What are the factors that empirical work behind it, and that can provide 14 Service Delivery with Muslim Clients 191 concrete suggestions to stakeholders. Intergroup reduce prejudice. The mediating effects of anxi- contact theory (or contact theory) is one of the ety reduction remained even when controlling for most widely investigated theories in social psy- the duration, quantity, and quality of the inter- chology and has its basis in natural observations group contact as reported by the participants. of intergroup change (Pettigrew, Tropp, Wagner, However, what is not clear is whether this effect & Christ, 2011). Contact theory was first pro- is related to, or better explained by, symbolic posed by Allport (1954), who suggested that con- threat. A review by Hodson (2011) supports the tact between outgroup and ingroup members can notion that anxiety reduction is a key process for improve intergroup relations, including reducing positive intergroup contact, especially for out- the impact of prejudice on the outgroup. Allport group intolerant members of a majority group. (1954) argued that four conditions are key for Gaddis and Ghoshal (2015) conducted a study intergroup contact to have positive effects: (1) in which they mass mailed applications for rental contact should occur between individuals of units to postings in several major US cities. The equal status, (2) groups should have shared goals, applications included Arab female names, as well (3) attainment of those goals should involve as indications of gainful employment and college cooperation between groups, and (4) sustained degrees. Gaddis and Ghoshal (2015) found that cooperation requires the involvement of institu- greater discrimination occurred with listings that tions and authorities. Pettigrew (1998) suggests a were geographically closer to mosques. Gaddis fifth condition that the contact in question allows and Ghoshal’s results orient the scientific com- the opportunity for friendships to develop munity to consider a potential paradox. between individuals. In an important meta- Specifically, there is evidence that intergroup analysis that examined findings from 515 studies, interactions can in fact produce negative effects Pettigrew and Tropp (2006) concluded that inter- of intergroup bias (i.e., MacInnis & Page-Gould, group contact generally reduces intergroup preju- 2015). However, there is a lack of consensus dice, and that more rigorously controlled studies about how robust these effects are, and at least show greater treatment effects, while also sug- one paper suggests that they are mediated by gesting that more research needs to be conducted social ties (Stolle, Soroka, & Johnson, 2008). that shows what factors might prevent the reduc- Contact theory has been successful in identi- tion of prejudice after intergroup contact. fying how some factors (especially positive Hutchison and Rosenthal (2010) examined the intergroup contact) lead to reduced prejudice role that anxiety may play as a mediator between from ingroups towards outgroups. However, Muslim-majority intergroup contact and atti- more research needs to be conducted to show tudes, perceived group variability and perceived how contact theory applies to acculturation in intentions. They note that perceived group vari- general, and to intergroup contact between ability (the degree to which one perceives an out- Muslims and Western cultures specifically. group as homogenous versus having variability What contact theory does presently support is between members), while related to decreased the importance of the healthcare provider as a prejudice, does not fully mediate it. In a pair of point of contact between the two. Muslims cross-sectional studies, Hutchison and Rosenthal report ambivalence and uncertainty about (2010) showed that anxiety about intergroup con- engaging with behavioral healthcare providers tact mediates the relationship between intergroup as well as healthcare providers in general. How contact and attitudes towards Muslims. While providers engage with Muslim clients, and the these studies cannot demonstrate causation and degree to which providers strive to provide cul- were conducted with convenience samples of turally competent care, has an impact not only White majority university students, they repre- on the individual client, but how the client’s sent an important step in characterizing the causal community perceives the helping professions pathway by which intergroup contact functions to writ large. 192 C. E. Stanton

Intervening with Muslim Clients Ibrahim and Dykeman (2011) for discussion of and suggestions for conducting cultural assess- Research on US Muslim and Muslim immigrant ment with Muslim clients, such as framework for populations points the way towards several assessment as well as some measurement potentially useful sets of guidelines for engaging suggestions. Muslim clients in behavioral health. However, it Beshai et al. (2013) provide an overview of is important to emphasize that recommendations the similarities and differences between the phil- presented in this chapter do not constitute a “cook osophical worldviews presented in both book” for providing effective services. The litera- cognitive-behavioral therapy (CBT) and Islam. ture to support developing step-by-step instruc- They note that for some followers of Islam, mentions on providing interventions in a culturally tal distress and symptoms are viewed as tests competent and effective manner is simply not from Allah, which may be alleviated by prayer there yet (Beshai, Clark, & Dobson, 2013). For and adherence to doctrine through personal con- example, a recent meta-analytic review found duct. Other authors suggest that CBT may in fact that faith-adapted cognitive-behavioral interven- be quite compatible with Muslim clients from tions (F-CBT), or CBT interventions that explic- conservative countries and cultural traditions. itly incorporate the spiritual or religious This may be because “basic CBT concepts are in perspective of the client into therapy, found that alignment with Islamic beliefs…CBT is suitable while F-CBT showed significant benefits, meth- for the conservative cultural constructs of the odological concerns of the study sample limit the populations, where patients initially attend ther- ability to draw any firm conclusions (Anderson apy with an apprehension [of self-disclosure]” et al., 2015). Another review found that even lit- (Algahtani, Buraik, & Ad-Dab’bagh, 2017, erature focused only on depression sometimes p. 114). The same authors also note that CBT contained contradictory advice or based claims provides a structure that is useful for Muslim cli- on poor or no evidence (Walpole, McMillan, ents to both present their concerns and safely House, Cottrell, & Mir, 2013). However, there build rapport. are generally effective stances and attitudes that Given the documented benefits of religious are likely to be useful in working with this popu- coping for Muslim clients, behavioral activation lation, such as the interview questions suggested (BA) may represent an adaptable intervention by Rassool (2015). that can be tailored to meet client’s needs (for Abu Raiya and Pargament (2010) summarize more information about BA itself, see Kanter, a wide literature about Muslim mental health and Manos, et al., 2010). BA is an efficacious treat- the role that Islam plays in the well-being of ment for depression and has previously been Muslim individuals. Drawing on empirical shown to be amenable to cultural adaptation research, they make five suggestions for psycho- (Kanter, Santiago-Rivera, Rusch, Busch, & West, therapy providers: (1) clinicians should inquire 2010; Kanter et al., 2015). In a mixed-method directly about the role that religion plays in the study, Mir et al. (2015) developed and evaluated client’s life, (2) clinicians should inquire the a version of BA for Muslim clients in an open degree to which the client identifies as a practic- trial. In discussions with community and profes- ing Muslim, and have basic background knowl- sional informants, the authors found that BA was edge of Islamic beliefs and practices, (3) not only a good fit for Muslim clients in terms of clinicians should help Muslim clients orient the orienting philosophy (citing Islamic values towards positive religious coping skills, (4) clini- that promote self-activation and an active stance), cians should assess, identify, and normalize reli- but also because BA itself is a highly customiz- gious struggles, referring to an imam when able intervention that is relatively easy to adapt appropriate, and (5) clinicians should dissemi- for any given client. The open trial found that a nate information about psychotherapy and psy- majority of participants reported positive chopathology to Islamic communities. See outcomes. 14 Service Delivery with Muslim Clients 193

Individuals who practice Islam and who have with Muslim clients is likely key for positive cultural values derived from Muslim countries outcomes. place value on the involvement of their social community and their imam in their recovery from mental and physical illness (Ali, 2016; Tobah, References 2017). Behavioral health providers should not be surprised if a Muslim client wishes to involve Abu-Bader, S. H., Tirmazi, M. T., & Ross-Sheriff, F. family members or their imam in their treatment. (2011). The impact of acculturation on depression among older Muslim immigrants in the United States. Such involvement of the client’s social milieu is Journal of Gerontological Social Work, 54, 425–448. typical; the limited literature on Muslim’s seek- Abu Raiya, H., & Pargament, K. I. (2010). Religiously ing out pastoral counseling suggests that Muslims integrated psychotherapy with Muslim clients: routinely consider it an option worth pursuing, From research to practice. Professional Psychology: Research and Practice, 41(2), 181–188. and even sometimes see secular mental health Adam, Z., & Ward, C. (2016). Stress, religious coping, providers and pastoral counselors concurrently and wellbeing in acculturating Muslims. Journal of (Ali, 2016; Ali, Milstein, & Marzuk, 2005). Muslim Mental Health, 10(2), 3–26. Ajrouch, K. J., & Kusow, A. M. (2007). Racial and religious contexts: Situational identities among Lebanese and Somali Muslim immigrants. Ethnic and Racial Conclusion Studies, 30(1), 72–94. Algahtani, H., Buraik, Y., & Ad-Dab’bagh, Y. (2017). Best practices for providing effective behavioral Psychotherapy in Saudi Arabia: Its history and cultural context. Journal of Contemporary Psychotherapy, health services to US born Muslims and Muslim 47(2), 105–117. immigrants are still not fully understood. There is Alhomaizi, D., Alsaidi, S., Moalie, A., Muradwij, N., a continued need for research and practice evalu- Borba, C. P., & Lincoln, A. K. (2017). An explora- ation in order to establish empirically informed tion of the help-seeking behaviors of Arab-Muslims living in the US: A socioecological model. Journal of guidelines (Anderson et al., 2015; Beshai, Clark, Muslim Mental Health, 11(1), 61–63. & Dobson, 2013; Walpole et al., 2013). Muslim Ali, S. (2008). Understanding acculturation among immigration is expected to continue, and geopo- second-generation south Asian Muslims in the United litical conflicts that are ongoing in the Middle States. Contributions to Indian Sociology, 42(3), 383–411. East and South Asia are likely to contribute to Ali, O. M. (2016). The Imam and the mental health of unique difficulties for the acculturation of Muslims: Learning from research with other clergy. Muslim immigrants. Given that Muslims have Journal of Muslim Mental Health, 10(1), 65–73. shown the ability to embody complex identities, Ali, S. R., Liu, W. M., & Humedian, M. (2004). Islam 101: Understanding the religion and therapy impli- as well as acculturate successfully to different cations. Professional Psychology: Research and societies around the world, promoting successful Practice, 35(6), 635. acculturation should be a priority for the behav- Ali, O. M., Milstein, G., & Marzuk, P. M. (2005). The ioral health practitioner. Acculturation, prejudice, Imam’s role in meeting the counseling needs of Muslim communities in the United States. Psychiatric and discrimination continue to have conse- Services, 56(2), 202–205. quences for Muslims and as a result, societies at Allport, G. W. (1954). The nature of prejudice. Reading, large. Readers who anticipate working with MA: Addison-Wesley. Muslim clients would do well to stay abreast of Al Wekhian, J. (2016). Acculturation process of Arab- Muslim immigrants in the United States. Asian Culture the latest scholarly findings that could inform and History, 8(1), 89-99. https://doi.org/10.5539/ach. effective practice (the Journal of Muslim Mental v8n1p89 Health is especially recommended for hopefully Anderson, N., Heywood-Everett, S., Siddiqi, N., Wright, clear reasons). J., Meredith, J., & McMillan, D. (2015). Faith-adapted psychological therapies for depression and anxiety: It is hoped that this chapter has provided use- Systematic review and meta-analysis. Journal of ful suggestions and areas for further reading for Affective Disorders, 176, 183–196. the clinician. Understanding context, both his- Ansari, H. (2004). The infidel within: Muslims in britain torically and presently situated, when working since 1800. London: Hurst. 194 C. E. Stanton

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Gabriela Hurtado, Laurie Cook Heffron, and Josephine V. Serrata

Introduction emigration which refers to leaving one’s country to settle somewhere else. The United States is home to more immigrants It is important to note that there are significant than any other country in the world (Pew differences in the experiences between immi- Research Center, 2016). According to the Pew grant groups. For example, the diversity in immi- Research Center (2016), there were also 43.7 gration is reflected on the different locations that million immigrants in the USA in 2016, account- are the most common birthplaces for US immi- ing for approximately 13% of the population in grants: Mexico (11.6%), China (2.7%), followed the country. There are several definitions used by by India (2.4%), the Philippines (1.9%), and El the government to differentiate among immigrant Salvador (1.4%) (Pew Research Center, 2018). groups (e.g., refugee, asylum-seeker1). For the These countries have vastly different sociopo- purposes of this chapter, we will be using the litical histories of immigration to the term immigrant to indicate someone that was not USA. Altogether, the diversity of the groups born in the USA and has moved to with the pur- immigrating to the USA, along with the compose to settle in the country permanently. We plexities and intricacies of the US immigration would like to also distinguish this process from system, must be considered as they might impact the experiences and stressors to which these groups are exposed to during post-migration. Adapting to life in the USA can be a challeng- 1 According to the Department of Homeland Security ing experience accompanied by high levels of (2019), (1) a refugee is a person that is not living in their stress (Berry, 2006a). Learning a new language, country of origin and cannot return due to fear of persecution, and (2) asylee refers to a person that meets the crite- isolation, loss of social support, and experiences ria for refugee and is either at a port of entry to the USA of discrimination, are examples of the stressors or already in the country. frequently experienced by immigrants. In addition to post-migration stressors, immigrants G. Hurtado (*) · J. V. Serrata sometimes have also experienced difficult experi- Prickly Pear Therapy and Training, Austin, TX, USA ences in their countries of origin. These circum- e-mail: [email protected]; stances can amplify the impact of present [email protected] stressors that result from their adaptation to life L. C. Heffron in the USA. Available evidence suggests that School of Behavioral and Social Sciences, St. Edwards University, Austin, TX, USA these stressors, both at the pre- and post-migration e-mail: [email protected] stages, are linked to negative mental health out-

© Springer Nature Switzerland AG 2020 197 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_15 198 G. Hurtado et al. comes such as depression, anxiety, and suicidal clinical settings. Our main goal is to identify thoughts (Cho & Haslam, 2010; Hovey, 2000; areas of need for this group and provide recom- Rasmussen et al., 2012; Sirin, Ryce, Gupta, & mendations to be used in the day-today delivery Rogers-Sirin, 2013). of mental health services that are culturally The evidence presented above indicates that responsive to immigrant individuals. this population is at risk for experiencing high levels of stress, which highlights the need to access mental health services. Mental health treatment Barriers to Behavioral Health can be helpful in preventing negative outcomes Service Delivery and strengthening the use of effective coping strategies. Unfortunately, despite the evidence that As mentioned above, significant disparities exist immigrants may face a greater need for mental in service access and utilization among immi- health services after settling in the USA, we see grant groups. Those individuals with mental dis- overall lower mental health service utilization, in orders may be significantly more likely to have comparison with non-immigrants (Bridges, sought medical care, but not psychiatric services Andrews, & Deen, 2012; Chen & Vargas- (Bridges et al., 2012). Those with college degrees Bustamante, 2011). Disparities in utilization of or higher are also more likely to seek services mental health services are exacerbated by struc- (Fortuna, Porche, & Alegria, 2008). Among tural barriers. Existing interventions for mental immigrant communities, lower rates of use are health have been designed based in studies with a pronounced among men, those with no health majority of non-immigrant, English-speaking, insurance, and those without documentation in white sample; therefore, they might not address the USA, as well as among younger immigrants the needs of the immigrant population in the USA. (Derr, 2015). Interestingly, as age at the time of Although some researchers have called for the immigration increases, the likelihood of service adaptation of existing treatments in order to be use decreases (Lee & Matejkowski, 2012). able to provide treatments that are culturally Behavioral healthcare needs may be recog- responsive to immigrant communities (Griner & nized, but not necessarily prioritized, among Smith, 2006), there continues to be a significant immigrant families, depending on the host of gap in the delivery of mental health services for other immediate and basic needs and/or risk of and with immigrant communities. Additionally, deportation faced by some (Zayas et al., 2017). As the current sociopolitical climate in the USA cre- mentioned above, immigrant families face a myr- ates a significant barrier for reducing health dis- iad of stressors that impact behavioral health and parities among immigrants. More specifically, decisions to seek help or support for mental health the anti-immigration policies in the past two needs. These include challenges related to eco- decades and exacerbation of current anti- nomic stability, discrimination, socio-cultural and immigrant sentiment in the country impose not linguistic adjustment, parenting and family only additional stressors for immigrant groups, dynamics, employment, and immigration status but interfere with the access to health services by (Saechao et al., 2012). This section addresses bar- instilling fear in these communities (Amuedo- riers to access to behavioral health services among Dorantes, Puttitanun, & Martinez-Donate, 2013; immigrant communities—structural barriers, cul- Garcini et al., 2017; Paat & Green, 2017; Salas, tural barriers/perceived need for services, social Ayón, & Gurrola, 2013). In this chapter, we aim support and stigma, immigration-related barriers, to identify the barriers to the delivery of mental and prior exposure to abuse or violence. health services for immigrants, discuss the current sociopolitical context of immigrant popula- Structural Barriers Several structural barriers tions in the USA, and review the considerations contribute to the disproportionately lower use of and the guidelines that have been developed to behavioral health services among immigrants. address the needs of the immigrant population in First, immigrant communities are negatively 15 Behavioral Health with Immigrants 199 impacted by the high cost of services, coupled public charge rules. Those who have migrated with limited access to health insurance coverage to the USA for a variety of complex and inter- (Bridges et al., 2012; Chen & Vargas-Bustamante, related reasons may be detained, sometimes 2011; Fortuna et al., 2008; Lee & Matejkowski, with their young children, in large, locked facil- 2012). Among non-citizen immigrants, those ities without access to legal representation, with health insurance are more likely to use men- adequate mental health services, or other ser- tal health services than those without; however, vices and supports. Negative bio-psychosocial those without citizenship are less likely than their impacts of detention compound the stress, vio- citizen counterparts to have health insurance (Lee lence, and/or trauma immigrants may have & Matejkowski, 2012). In addition to lack of experienced before, during, and after migration health insurance, limited and inadequate linguis- (Coffey, Kaplan, Sampson, & Tucci, 2010; tic access to mental health services serves as a Robjant, Hassan, & Katona, 2009). The nega- structural barrier to care (Falgas et al., 2017; tive psychological impacts of detention, in Fortuna et al., 2008; Saechao et al., 2012). addition to the increased need for mental health Importantly, systemic racism and anti-immigrant services after release from detention, are well or xenophobic sentiments also serve as barriers to documented in the literature (Coffey et al., help-seeking and access to services (Bauer, 2010; Davis, 2014; Fazel & Stein, 2002; Keller Rodriguez, Quiroga, & Flores-Ortiz, 2000). et al., 2003; Robjant et al., 2009; Silove, Austin, & Steel, 2007; Steel et al., 2006). Immigration-related barriers represent an In addition, this context is complicated by important consideration in understanding help- recent reports of human rights violations, such as seeking and service use among immigrant com- acts of harassment and violence within detention, munities. Immigration status influences access to as well as, limited access to mental health ser- and use of behavioral health care among immi- vices within detention settings (Cantor, 2015; grants, and individuals’ legal immigration status, Cook Heffron, 2019; Cook Heffron, Serrata, & fear of being denied services due to status, fear of Hurtado, 2018; UT Immigration Law Clinic, deportation, anxiety about being asked for docu- 2018; Women’s Refugee Commission, 2017). An mentation, and experiences of discrimination additional factor in considering access to and use from health care providers negatively contribute of services, is the recently published changes to to behavioral health care utilization (Bridges the “public charge” policies in October 2018. et al., 2012; Derr, 2015; Falgas et al., 2017; Proposed changes could result in the use of social Fortuna et al., 2008). welfare programs such as Medicaid, SNAP (food In addition to the enduring and negative stamps), and some housing assistance programs impacts of historical anti-immigrant policies, counting against immigrants seeking to adjust several recent practices and policies are impor- their status. Advocates fear that immigrants may tant to consider in understanding the current forego needed public benefits, in addition to more political landscape faced by immigrant commu- wide-ranging medical and mental health services, nities in need of behavioral health services. in order to protect future immigration remedies Current immigration policies and practices may (www.childrensdefense.org). serve as barriers to meeting the mental health In particular, refugee and asylum-seeking needs of some immigrant communities (Zayas immigrants show increased need and higher ser- et al., 2017). It is critical to examine, for exam- vice use rate than other immigrant and non- ple, restricted access to immigration legal rem- immigrant groups (Derr, 2015). Help-seeking edies such as U Visas, expanded use of and access to family violence services is an immigrant detention, immigrant family separa- important consideration for immigrants, asylum- tion, changes to domestic violence-based asy- seekers, and refugees who experience violence lum, delays in processing immigration-related before, during, or after migrating to and settling applications, and proposed strengthening of in the USA. In fact, immigrants often live in, 200 G. Hurtado et al. and/or are exposed to high levels of poverty, USA increases and among those who know community violence, and discrimination, and someone who has utilized mental health ser- while some immigrants may migrate to find pro- vices (Bridges et al., 2012). Even given knowl- tection or relief from political violence (and/or a edge and information about the US system, host of other pre-migration conditions, stressors, immigrant communities may have little trust in persecution, or trauma), they may encounter the effectiveness of treatment options, further additional exposure during immigration and contributing to lower rates of service use (Falgas after settling in the USA (Fortuna et al., 2008). et al., 2017). In addition, stigma about mental Those previously exposed to abuse or violence health and mental health services in the country (such as political violence or intimate partner of origin contributes to lower use of mental violence) may have limited access to and may be health services (Saechao et al., 2012). In partic- less likely to seek behavioral health services and ular, gender norms and expectations related to other services that aim to respond to survivors of masculinity and emotional vulnerability may abuse and violence (Menjívar & Salcido, 2002; serve as an additional barrier for immigrant men Raj & Silverman, 2002; Warrier & Rose, 2009). (Fortuna et al., 2008). Similar to the broader immigrant community, barriers to help-seeking and access to services It is important to note that the formal service among survivors of violence include language delivery system is not the only source of poten- barriers, lack of awareness or information, fear tial care or support, and immigrants may be more of immigration consequences, pressure to main- likely to turn to alternative service providers, tain traditional gender role expectations, dis- religious or spiritual leaders and healers, and/or crimination, the impact of migration-related social support networks as sources of behavioral trauma, and contemporary immigration policies healthcare (Bridges et al., 2012). Social support and practices (Bauer et al., 2000; Dutton, Orloff, may be particularly important, as immigrants are & Hass, 2000; Reina, Lohman, & Maldonado, more likely to seek help first from family, friends, 2014). While immigrant survivors may have or religious/spiritual leaders. These networks extensive knowledge of formal and informal impact help-seeking behaviors and influence supports in their countries of origin, they may immigrants’ identification of the need for treat- lack awareness of the service context in the USA ment, as well as the initiation of treatment (Wachter & Dalpe, 2018). Similar to the broader (Falgas et al., 2017). Help-seeking from social immigrant community, undocumented or pre- support networks and alternative treatment pro- carious immigration status negatively impacts viders (such as homeopathy, acupuncture, and survivors’ likelihood of seeking formal help traditional healers) are not necessarily connected (Frías & Angel, 2005; Guruge & Humphreys, with lower formal service use, though they may 2009; Levine & Peffer, 2012; Zadnik, Sabina, & be related to delayed treatment by medical and Cuevas, 2016). mental health professionals (Derr, 2015). Unfortunately, social support networks often Cultural Barriers In addition to structural shift and may temporarily weaken during or fol- barriers, a number of cultural factors also influ- lowing migration (Ayón, 2018). ence access to and use of behavioral healthcare. First, newcomers’ lack of knowledge of the mental health service delivery system in the Understanding the Sociopolitical USA—where and how to seek treatment— Context of Immigrant Populations serves as a barrier to immigrants in need of treatment (Chen & Vargas-Bustamante, 2011; Ecological Framework The original ecological Saechao et al., 2012). Research finds that ser- model proposes that an individual’s experience vice utilization among immigrants increases as is shaped by the interactions between them- knowledge about mental health services in the selves and their environment (Bronfenbrenner 15 Behavioral Health with Immigrants 201

1979). This framework was then expanded to context and sociopolitical climate of immigrant also include home, school, community, values, communities. Clinicians can then ask questions and society at large as well as the interactions about the experiences that individuals might be of these systems with one another as contex- having outside the therapeutic room that might tual factors that impact individual behavior exacerbate their mental health outcomes, make it (Bronfenbrenner, 1989). difficult for them to engage in services, and/or interfere with treatment adherence. Moreover, it This model has been used to understand the provides clinicians a lens to contextualize some acculturative process given that this is a multi- of the symptoms that immigrant individuals level model that accounts for proximal and distal might be reporting during the initial assessment factors that affect immigrants’ mental health out- stage and throughout treatment, in addition to comes. Acculturation refers to the process in helping clinicians formulate treatment plans that which individuals change and adapt as a result account for their sociopolitical environments. from interacting with a different cultural context Jensen (2007) also provides a description of (Berry, 2006b; Gibson, 2001). For example, how this model can be used to gain a more in- Serdarevic and Chronister (2005) explain that the depth understanding of the experiences of immi- ecological framework accounts for the complex grants in the USA (see Fig. 15.2). More bidirectionality of factors that are part of the specifically, he highlights those factors that can immigration and acculturative processes (see promote well-being at different environmental Fig. 15.1). In clinical practice, using this model levels. This information can be integrated in the allows providers to understand an individual’s delivery of mental health treatment to promote chronosystem, which refers to the transitions or effective coping strategies and bolstering cultural changes that occur through time (Neal & Neal, factors that already contribute to resiliency in this 2013). This system will include the historical group.

Fig. 15.1 Theoretical conceptualization of the Macrosystem role of context of Gender roles immigration processes. Culture Values (From Serdarevic & SES Chronister, 2005) Exosystem Public Policy

Mesosystem Relationships among microsystems

Microsystem Family Friends Work Church

Individual Sex Cognitive factors Biological mechanisms 202 G. Hurtado et al.

Antecedents Mesosystem Reason(s) for Immigrating Child Acculturation(stress) Predeparture Circumstances Conflict Between Microsystems Trauma During Move Practices Stressors due to Leaving Values Loss of Homeland Beliefs Loss of Family Culture Loss of Friendships Language Loss of Routine Change in Interactions Exosystem Uncertainty Parent Acculturation (stress) Fear Access to Familiarity Language Microsystem Culture Home Interactions Customs School Interaction Lack of Social Support Network Peer Interaction Economic Pressure Psychological Immigration Individual Factors Fear of Deportation Temperment Local Legislation Well-Being Beliefs Access to Public Services Age Sex Macrosystem Motivation General Cultureof New Society Self-Esteem Belief Systems Resilience Hazards Locus of Control Lifestyles Bicultural/Bilingual Skills Opportunity Structure Family Patterns in Social Interchange Parental Stress Level Discrimination Parental Warmth Prejudice Communication Stability

Mediating Processes

Fig. 15.2 Multilevel model of mediator factors of immigration and well-being. (From Jensen, 2007)

Ethnoracial Trauma An important element of Vinhas, & Gonzalez-Vazquez, 2012; Rasmussen the ecological framework that is particularly et al., 2012). As mentioned above, the exposure salient for immigrant communities seeking men- to traumatic events can result in a negative impact tal health services is that of ethnoracial trauma. to the mental, physical, and overall well-being of The immigration process consists of different immigrant individuals. Exposure to traumatic stages, the pre-migration experience in an indi- events can also exacerbate pre-existing mental vidual’s country of origin, the journey to the and physical health symptoms, especially for USA, and the post-migration experience once the those that have experienced violence previous to individual has arrived in the USA (Perez Foster, their immigration experience. In addition, when 2001). It is important to note that the migration individuals arrive to the USA, they can experi- process is often fluid; therefore, individuals ence threatening conditions, including detention might go through these stages in a way that is in centers where their physical and psychological non-linear with continued mobility across space. needs are not met, human trafficking, exploita- There are multiple reasons why people might tion and forced labor, isolation, and poverty choose to migrate to the USA. Some people (Chavez-Dueñas, Adames, Perez-Chavez, & experience poverty or violence (e.g., persecution, Salas, 2019; Cook Heffron et al., 2018). domestic violence, interpersonal violence) in Since the 2016 election, when President their country of origin. Others have opportunities Trump bolstered nativist views throughout his for work and education, or they might have fam- campaign, including making demoralizing state- ily members that have already migrated. ments about ethnoracial minorities and promoted the construction of a wall at the border with Available studies suggest that immigrants are Mexico, there has been a rise in a broader anti- at a high risk for undergoing traumatic experi- immigrant climate and increased fear among ences throughout the migration process (Casillas, immigrant communities (Chavez-Dueñas et al., 2006; Infante, Idrovo, Sanchez-Dominguez, 2019). Chavez-Dueñas et al. (2019) also note that 15 Behavioral Health with Immigrants 203 this environment can lead to ethnoracial trauma, gests a connection between the words that we use a response characterized by increased distress to describe our emotions and affective experi- and fear due to experiences of systemic oppres- ences (Brooks et al., 2017). In fact, research find- sion, that can take place at the individual level but ings suggest that mental health interventions also has a significant effect on families and provided in an individual’s preferred language communities. are more effective than those delivered in English Families and communities might worry about (Griner & Smith, 2006). Thus, being able to use its members being victims of hate crimes and our native language to describe our experiences, other instances of abuse and racism. The increased thoughts, and perspectives and understand those fear from immigrant communities is not of others is imperative in the delivery of mental unfounded as hate crimes rates have continued to health interventions. increase since 2016 (U.S. Department of Justice, 2017). In addition, there is also great fear of com- In the USA approximately 22% of people munity members being arrested, detained, and/or report that they speak a language other than deported. In 2017, there was a 30% increase in English at home (Migration Policy Institute, administrative arrests by Immigration and 2018); therefore, the recommendations regarding Customs Enforcement (ICE) and Customs and the reduction of health barriers with immigrant Border Protection (CBP) (U.S. Immigration and groups have emphasized language accessibility. Customs Enforcement, 2016, 2017), and an 11% This concept typically refers to having services increase between 2017 and 2018 (Zong, Batalova, available in such a way that an individual can & Burrows, 2019). Moreover, major changes to understand and communicate effectively (e.g., immigration policies include the entry ban to indi- translation or interpretation in their preferred lan- viduals from majority-Muslim countries, reduc- guage) (Antena, 2012). However, when providers ing the number of allowed refugee admissions, do not take into consideration literacy level, cul- attempts to cancel the Deferred Action for tural views, and cultural context, they are not yet Childhood Arrivals (DACA) program, and ending providing culturally relevant services. Therefore, the Temporary Protected Status for several groups we turn to a language justice framework that (Zong, Batalova, & Burrows, 2019). There has applies social justice principles to language also been an expansion in the authority of ICE and accessibility. the number of agents for immigration enforce- Language justice focuses on ensuring that the ment, as well as changes to the prioritization for level of reading and translation should be acces- deportation policies (National Immigration Law sible to individuals of most socioeconomic and Center, 2017). This climate of fear can place educational backgrounds, as well as those with immigrant communities at a heightened vulnera- special needs (Antena, 2012). This can be com- bility for other crimes as it will be less likely for plicated as this might differ per country of origin. them to seek help from local authorities, such as Hiring qualified interpreters, involving individu- reporting crimes (e.g., domestic violence, sexual als that can connect with clients to explain the abuse, exploitation) and seeking services for materials, and use of cultural references and cus- physical and mental health. toms, can all be helpful in closing the gap of linguistic differences and creating an inclusive environment (Antena, 2012). Considerations in Behavioral Health Service Delivery with Immigrant Cultural Responsiveness Cultural responsive- Populations ness refers to the ability to provide mental health services that are adequate for multicultural popu- Language Accessibility and Justice Language lations. This means that the needs of these popu- is an integral part of who we are and how we lations regarding mental health can be fulfilled experience the world. Extensive evidence sug- within an appropriate cultural context. The 204 G. Hurtado et al.

American Psychological Association (APA) has Cultural adaptation of evidence-based prac- released updated guidelines to provide culturally tices is done to adjust the intervention to the con- competent services to multicultural groups. In text of the individual (Bernal, Jimenez-Chafey, & these guidelines, they outline the importance of Domenech Rodriguez, 2009). This can be the therapist’ understanding of different cultural achieved through the use of principles that groups and their values, as well as their use of emphasize flexibility, openness, and culturally skills and practices that are culturally centered meaningful strategies (e.g., use of metaphors or (American Psychological Association, 2017). content that is relevant to the client’s experiences) (Bernal & Saez-Santiago, 2006; Smith, In addition to the guidelines to providing Domenech-Rodriguez, & Bernal, 2011). care to multicultural groups, APA has also There has been some debate about the adapta- released an additional update for clinicians tion of available evidence-based practices in based on their Taskforce on Immigration order to meet the needs of diverse groups, such as (American Psychological Association, 2012). ethnoracial minorities and immigrants. Concerns The update highlights important considerations about this process center on the balance between in the provision of mental health services to cultural-specificity and treatment fidelity. The immigrant individuals. These considerations consensus now is to create culturally responsive include the different stages of the migration modifications while maintaining the treatment experience, language accessibility, symptom factors that have been identified as mechanisms expression, gender and intergenerational roles, of change in an existing intervention (Smith economic stressors, marginalization and oppres- et al., 2011). sion, resilience, and intersectionality (American Several studies have found cultural adapta- Psychological Association, 2012). tions of evidence-based treatments to be effective In addition to the consideration of the factors (Koslofsky & Domenech Rodríguez, 2017; outlined above that reflect the experience of Griner & Smith, 2006). Some research groups immigrants in the USA, it is important that thera- have examined the effectiveness of adapted inter- pists examine their own knowledge, attitudes, ventions for immigrant populations. Through and biases about different immigrant groups, as their research they have identified meaningful well as their own privilege and blind spots regard- culturally responsive strategies for this group. ing issues of marginalization and oppression. The Some examples include, using group sessions to process of introspection is key in the provision of increase social support in a cognitive behavioral culturally responsive services as it will allow the intervention designed for PTSD and depression clinician to understand the impact of their own with low-income Latina immigrants in primary experience in the conceptualization of clients and care clinics (Kaltman, Hurtado de Mendoza, barriers that might arise in the implementation of Serrano, & Gonzales, 2016), or increased flexi- different therapeutic strategies. It should be noted bility around time and duration of sessions for the that cultural responsiveness is an ongoing pro- treatment of oppositional defiant disorder within cess that requires significant effort on the part of the context of intimate partner abuse with undoc- the clinician. umented individuals (Maríñez-Lora & Cruz, 2017). In short, using culturally adapted practices Evidence-Based Practices Evidence-based prac- and strategies when implementing evidence- tices are defined as those that integrate the avail- based interventions can be one strategy to able research evidence and clinical judgment increase access to mental health services and while taking into consideration the individual’s meet the needs of immigrant individuals. context (e.g., preferences and traits) (American Another approach to EBP includes working Psychological Association, 2005). Evidence- with immigrant communities themselves to based interventions have also been determined to develop and/or adapt approaches that might work be effective through clinical trials. best for them. As noted in the ecological model, 15 Behavioral Health with Immigrants 205 services directed at the individual level are one based on shared power and reciprocity. approach to supporting immigrant communities; Practitioners may first simply identify local however, interventions at the community level immigrant-serving organizations, particularly can also be effective at creating environments of immigrant-led initiatives, attend and support support that can buffer the sociopolitical stressors community events, volunteer time and skill to experienced by this community. The Community- existing efforts, and inquire where and how Centered Evidence Based Practice model one’s expertise can be of use to the community. (Serrata, Macias, Rosales, Hernandez, & Perilla, As relationships develop, practitioners may 2017) is an approach that offers tangible recom- begin to ensure that members of community- mendations on how to center specific community based organizations are included in decision- members in developing, adapting, and improving making opportunities that impact the design, interventions. Mental health practitioners should implementation, and evaluation of future mental be connected with and aware of immigrant- health interventions. This may involve prioritiz- servicing community-based organizations in ing immigrant perspectives in staff and consul- their communities as the stressors experienced by tant positions and on task forces, advisory immigrant communities are multi-layered and boards and boards of directors. Finally, it is require multi-layered tactics (see Fig. 15.3). important for mental health professionals to While the training many mental health prac- consider the ways that immigrant-serving orga- titioners receive may not serve as adequate nizations may be under-resourced and experi- preparation for community-based practice, ence exhaustion or secondary traumatic stress. practitioners may struggle with how to initiate Practitioners are often well-positioned to these connections. In building relationships address the impact of the work on communities with community organizations, it is critical that and community-based organizations, for exam- practitioners approach community organiza- ple, by offering support to address secondary tions with the authentic purpose of listening and trauma and burnout (e.g., offering healing ses- learning and seek to build relationships that are sions for staff).

Fig. 15.3 Community-centered evidence based practice model. (From Serrata et al. 2017) 206 G. Hurtado et al.

Conclusion Psychology of Immigration in the new century. Retrieved from https://www.apa.org/topics/immigration/immigration-report.pdf Recent statistics show that one in five US resi- Amuedo-Dorantes, C., Puttitanun, T., & Martinez-Donate, dents is born outside of the USA (Pew Research A. P. (2013). How do tougher immigration measures Center, 2016). In addition, 28% of the US popu- affect unauthorized immigrants? Demography, 50(3), 1067–1091. lation is comprised by immigrants and their chil- Antena. (2012). How to build Language Justice. dren (Migration Policy Institute, 2017). It is Retrieved from http://antenaantena.org/wp-content/ expected that this population increases to become uploads/2012/06/langjust_eng.pdf 36% of the US population by 2065 (Pew Research Ayón, C. (2018). “Vivimos en Jaula de Oro”: The impact of state-level legislation on immigrant Latino fami- Center, 2018). Altogether, these statistics note lies. Journal of Immigrant & Refugee Studies, 16(4), that immigrant communities are a significant por- 351–371. tion of the overall US population and this group Bauer, H. M., Rodriguez, M. A., Quiroga, S. S., & Flores- will continue to grow in the years to come. Ortiz, Y. G. (2000). Barriers to health care for abused Latina and Asian immigrant women. Journal of Health Immigration has become a more salient dis- Care for the Poor and Underserved, 11(1), 33–44. cussion in the current sociopolitical climate in Bernal, G., Jiménez-Chafey, M. I., & Domenech the USA within the past couple of years. As men- Rodríguez, M. M. (2009). Cultural adaptation of treat- tioned above, nativist and ethnocentric views ments: A resource for considering culture in evidence- based practice. Professional Psychology: Research continue to be enforced by changes in laws and and Practice, 40(4), 361. policy creating an anti-immigrant climate around Bernal, G., & Sáez-Santiago, E. (2006). Culturally the country. The present state of affairs poses a centered psychosocial interventions. Journal of significant challenge for those providing mental Community Psychology, 34(2), 121–132. Berry, J. W. (2006a). Acculturative stress. In P. T. health services to these communities as it ampli- P. Wong & L. C. J. Wong (Eds.), International and fies the already-existing structural and cultural cultural psychology series. Handbook of multicul- barriers that contribute to significant health dis- tural perspectives on stress and coping (pp. 287–298). parities in this group. Dallas, TX: Spring Publications. https://doi.org/10. 1007/0-387-26238-5_12 We aimed throughout this chapter to provide Berry, J. W. (2006b). Stress perspectives on acculturation. an overview of the immigrant community in the In D. L. Sam & J. W. Berry (Eds.), The Cambridge USA, as well as some of the challenges that this handbook of acculturation psychology (pp. 43–57). group might experience throughout their immi- New York, NY: Cambridge University Press. Bridges, A. J., Andrews, A. R., III, & Deen, T. L. (2012). gration experience. In addition, we hope to Mental health needs and service utilization by Hispanic highlight the considerations that providers must immigrants residing in mid-southern United States. have in their day-to-day service delivery in Journal of Transcultural Nursing, 23(4), 359–368. order for intervention and strategies to be cul- Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. turally responsive. Cambridge, MA: Harvard University Press. Bronfenbrenner, U. (1989). Ecological systems theory. Annals of Child Development, 6, 187–249. References Bronfenbrenner, U., & Morris, P. A. (2006). The bioeco- logical model of human development. In R. M. Lerner & W. Damon (Eds.), Handbook of child psychology. American Psychological Association. (2017). Theoretical models of human development (pp. 793– Multicultural guidelines: An ecological approach to 828). Hoboken, NJ: Wiley. context, identity, and intersectionality. Retrieved from Brooks, J. A., Shablack, H., Gendron, M., Satpute, A. B., http://www.apa.org/about/policy/multicultural-guide- Parrish, M. H., & Lindquist, K. A. (2017). The role lines.aspx of language in the experience and perception of emo- American Psychological Association Presidential Task tion: A neuroimaging meta-analysis. Social Cognitive Force on Evidence Based Practice. (2005). Report of and Affective Neuroscience, 12(2), 169. https://doi. the 2005 presidential task force on evidence-based org/10.1093/scan/nsw121 practice. Retrieved from https://www.apa.org/prac- Cantor, G. (2015). Hieleras (Iceboxes) in the Rio tice/resources/evidence/evidence-based-report.pdf Grande Valley Sector. Washington, DC: American American Psychological Association Presidential Task Immigration Council. Force on Immigration. (2012). Crossroads: The 15 Behavioral Health with Immigrants 207

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Susan Stuntzner and Jacquelyn A. Dalton

Introduction read, concentrate, communicate, and work (ADA, 1990). Disability census figures indicate that one in five Learning to live with a disability is a process Americans, approximately 20%, live with a dis- and one that sometimes resembles a significant ability (US Census, 2010). As a collective, people transition for the person and the family. While with disabilities comprise the largest minority many people adapt to the disability and move for- group, yet it is one of the least understood and ward in a positive fashion, some do not. Clinicians discussed. Disability is a term used to describe working with people with disabilities are likely to any number of physical, mental, emotional, psy- encounter people from both sides of the adjust- chological, cognitive, learning, neurological, ment continuum. Some people may seek short- sensory, and health conditions that limits one or term services while others require more intensive more major life activities (ADA, 1990). supports. Still other individuals may not desire or Examples, although not an exhaustive list, require any sort of behavioral health services, and include spinal cord injury, traumatic brain injury, thus, they never seek the services of a clinician or cancer, fibromyalgia, anxiety, depression, learn- behavioral health professional. ing disabilities (i.e., ADHD), diabetes, chronic Professionals who work with persons with pain, vision impairments, deafness/hearing loss, disabilities may have a number of questions or posttraumatic stress disorder, mental health con- assumptions that have not been addressed as a ditions (i.e., schizophrenia, bipolar disorder), and part of their education or training. As result, some cardiac conditions. According to ADA’s defini- may unintentionally think that a person’s disabil- tion, disability may impact a person’s ability to ity and the changes they experience directly care for oneself, do manual tasks, see, hear, eat, related to the disability are of primary importance sleep, walk, stand, lift, bend, speak, breath, learn, to the individual when they are not. While it is true that some individuals and their loved ones have questions or concerns related to the disabil- S. Stuntzner (*) ity and want assistance in moving past it, it is Southwestern Oregon Community College, imperative for clinicians to understand that dis- Coos Bay, OR, USA ability adjustment is only one piece of the coping University of Texas Rio Grande Valley, equation and in learning to live life to the fullest. Edinburg, TX, USA For many, learning to live well with a disability is e-mail: [email protected] much more involved and complex of a process, J. A. Dalton and many factors must be considered and East Central University, Ada, OK, USA

© Springer Nature Switzerland AG 2020 211 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_16 212 S. Stuntzner and J. A. Dalton addressed as a part of the therapeutic relation- fact that people are shaped by their upbringing, ship. For this reason, clinicians and behavioral earlier life experiences, lack of exposure, and health professionals are encouraged to learn as professional training. However, clinicians work- much as they can about disability and the experi- ing with this population need to do more, espe- ences of persons with disabilities. In an effort to cially given the fact that most mental health and help clinicians broaden their understanding and behavioral health programs do not incorporate to enhance their effectiveness in working with training and coursework pertaining to people this group of individuals, select topics are cov- with disabilities. Programs that do may only ered as a part of this chapter. It is our hope that as cover one course and these may refer to “excep- professionals read this chapter they digest and tional children, persons with learning disabilities apply the content provided to expand their under- or intellectual disabilities” and typically do not standing of persons with disabilities and as a part cover the broader range of conditions experi- of their clinical practice. enced by people nor do they consider ways to integrate the needs of people with disabilities into the professional curriculum (Olkin & Pledger, Language and Perspectives: 2003, p. 297). Olkin and Pledger (2003) expand Considerations for Clinicians our understanding of the lack of adequate coverage of this area by stressing the findings of a large Living with a disability is about much more than study of graduate psychology programs con- a diagnosis or a lifelong condition. Too often, ducted by Bluestone, Stokes, and Kuba (1996). someone with a disability is viewed by society, Bluestone et al. (1996) report that disability when professionals, and external bystanders as a per- compared to other diversity categories (i.e., eth- son who is different and somehow not a “whole nicity, gender, religion, socioeconomic status) person” because of the disability. While many of was the least addressed among professional pro- these views date back several hundreds of years grams and throughout the curriculum. Such find- and are a part of our history and the nation’s ings help us better understand that many foundation (Rubin & Roessler, 2008), such per- clinicians and helping professionals graduate spectives are still present. In these instances, from their programs with no or limited informa- persons without a disability and society, as a tion about the needs of persons with disabilities whole, focus on the feature that makes the per- or potential strategies to assist them in their clini- son different from other people. Thus, it is the cal practice. disability and the noticeable functional differ- Clinicians can increase their understanding ences brought about by the disability that and effectiveness in working with people with become the most salient part of the individual disabilities by learning more about this diverse rather than viewing the person as an individual group of individuals, their clinical concerns (i.e., comprised of multiple traits and characteristics self-concept), the obstacles and societal stigma (Stuntzner, 2012). they encounter, information pertaining to coping Clinicians who work with persons with dis- and adaptation, and therapeutic strategies (i.e., abilities are not exempt from holding negative forgiveness, self-compassion, resilience) that beliefs and stereotypes about people with dis- can be employed. Furthermore, professionals abilities simply because they are in a helping pro- have an opportunity to consider their own behav- fession. Despite their good intentions, clinicians iors and approaches when working with this are subject to engaging in undesired behavior group of people, some of which includes exam- such as focusing upon the person’s disability or ining the use of proper language, one’s own diagnosis as the most important feature of the beliefs about and expectations of persons with person instead of on the individual as a human disabilities, and viewing people from a holistic being. Some of this may be understood by the perspective. 16 Behavioral Health and Disability 213

Proper Use of Language without recognizing it, the negative views and and Diagnosis expectations held by society, family, and people they know. Thus, the last thing people need as Language is powerful and has the ability to help, part of the therapeutic relationship is more nega- heal, or hurt and suppress. While many of us may tivity or some sort of lowered expectations. desire to use it for positive purposes, such as a Related is the notion that language has the ability healing agent or as a means to encourage others, to affect how people view themselves and their it is important to be aware that language has the abilities. As clinicians and allied helping profes- potential to offend or hurt others. No one under- sionals, our goal is to help and empower people, stands the power of language better than the per- not to be another set of experiences that resem- son who has been on the receiving end of other bles some form of barrier or hurdle to be dealt peoples’ unkind words, slights, or derogatory with or overcome. comments. Clinicians are encouraged to consider their Language, inaccurate descriptors, and the use own use of language and to further examine if of labels are valid and vital concerns of many and when a diagnosis is indeed necessary. A persons with disabilities. Many of these negative good place to start is with the use of “person- descriptors include outdated words and phrases first” language. While it is true that some people such the words “invalid, suffering, afflicted, with a disability may not use “person-first” lan- abnormal, victim, moron, handicapped, wheel- guage themselves, most people prefer to be chair bound, and crippled” (Titchokosky, 2001, known as a person with unique qualities and p. 127). Others include the infamous “D” words characteristics and not as the condition or the often associated with a disability such as disability (Stuntzner, 2015b). Thus, it is impor- deformed, diseased, and disordered (Stuntzner, tant to separate the person from the disability/ 2015a). Such words, even if unintentional, have diagnosis and to become familiar with the per- the ability to hurt the therapeutic relationship, son as an individual the same as we would any- create distance, and promote negative thoughts one else without a disability. Even better of a and feelings about people with disabilities among practice is to address the person by his or her each other and as a part of the therapeutic first name (Stuntzner & Hartley, 2014a). In the relationship. event that people describe themselves in ways Being mindful of our word choice is impor- that are not encouraged (i.e., “I am handi- tant. Beyond the impact that it can have on the capped”), it is imperative that professionals therapeutic relationship is the way words can respect the person’s identity and description and negatively impact the person with a disability. take the time to explore what that means to the People come to counseling in hopes of being individual. Professionals who are uncertain of unconditionally accepted for who they are and to how to talk about a person’s disability are be valued for the experiences they have had. encouraged to enlist the preferred method which When working with people with disabilities, is to simply ask the individual what his or her these experiences often involve a history of being preference is (Stuntzner & Hartley, 2014a). oppressed, disempowered, and not being valued In terms of language as it pertains to diagno- or heard (Smart, 2009; Stuntzner, Dalton, & ses and labels, caution is encouraged. While MacDonald, 2018). Many have a long history of many people desire to understand, classify, and being told what they can or cannot do, what is categorize, as professionals we are held to a dif- and is not realistic because of the disability, or ferent standard and we must keep in mind the some form of negative expectations and lack of reasons and rationale for which diagnoses and support due to the specific type of disability or a labels are used. Clinically speaking, three criteria person’s gender (i.e., female) while living with a should be considered when it comes to the use of disability (Nosek & Hughes, 2003). Because of diagnoses and labels. These include the follow- these experiences, people sometimes internalize, ing (Stuntzner, 2015a): 214 S. Stuntzner and J. A. Dalton

• Is a diagnosis necessary for billing insurance these reasons, as clinicians working with persons companies? with disabilities, it is imperative that we step • Is a diagnosis needed to determine or justify back from our own set of experiences and exam- treatment of a mental health or physical condi- ine our own understanding and beliefs about dis- tion? or ability, persons with disabilities, and what we • Is a disability determination needed to be eli- think it means to have a disability. gible or to qualify for a service or program? One method Stuntzner and colleagues (Stuntzner, 2012; Stuntzner, Hartley, & Ware, Should our work with people address one of 2014) use as an educational tool among students, these questions, then the use of a diagnosis may professionals, and society at large to promote be warranted. However, outside of the need to sensitivity and awareness about disability and the seek payment for treatment or services, or to ways we relate to people based on one identified qualify for services by an agency, professionals feature is a visualization exercise called, “A Time are encouraged to refer to the person as a person, to Reflect and Remember.” In this exercise, peo- not the condition, and to view the person in a ple are asked to think about their life and to recall holistic manner the same as they would the per- one specific event that was hard and that they son without a disability. would not want to relive. Throughout this visualization, people are encouraged to remember the event, their thoughts and feelings associated with Examining Our Own Belief it, and how they were treated by other people and and Expectations to explore what stands out or is most salient about the situation. When people are finished, they are Individual and personal differences are a natural directed to consider how they would feel if peo- part of the human experience and society. Each ple, everyone they knew or met, identified and one of us has a different physical structure, facial related to them based solely on that time in their features, personality characteristics, personal life. Following, people are asked to get in touch preferences, cultural and ethnic background, and with how that would impact them if this “identi- personal beliefs and expectations. It is these dif- fied event” became the “sole feature” of who they ferences that make life and the human experience were to those around them and were not allowed diverse, interesting, and ever changing. Most to move past it. As you can imagine, many people people seem to accept these differences as a nor- would not like it. Our response to that is, mal part of life and as acceptable. However, “Knowing this, how might some people with a when we factor in the presence of a disability, the disability feel when people see them as the dis- equation often changes along with people’s per- ability and focus on that as the person’s identity ceptions, beliefs, and expectations. More specifi- rather than as a person with several interests, cally, disability is an experience that is often capabilities, and worthwhile characteristics?” accompanied by low expectations, social and Such an activity, becomes a springboard for pro- personal stigma, social isolation, loss or change fessionals to gain insight into the value of treat- in social and familial support, unemployment, ing people as holistic, valued individuals as well and lack of resources and if unchecked leads to a as a means to begin exploring their own beliefs continued path of inaccurate beliefs, perceptions, and expectations about persons with disabilities. bias, and misunderstanding (Marini, Glover- Beyond this visualization exercise, clinicians Graf, & Millington, 2012; Smart, 2009). One are encouraged to embark upon the personal feature of particular merit is the fact that persons journey of exploring their upbringing, prior expe- with disabilities are often looked at as the dis- riences and understanding of disability and per- ability, as previously mentioned, compounded by sons with disabilities, and their personal and the fact that people are often viewed as individu- professional beliefs and expectations. Questions als who cannot do or achieve something. For for consideration may include: 16 Behavioral Health and Disability 215

• What beliefs do I hold about living with a many inaccurate perceptions and is often misun- disability? derstood by “outsiders” (Wright, 1991). • Would I consider myself as a person who sees According to this definition, outsiders are a person’s strengths and abilities despite the depicted as people without a disability who are disability or do I focus on what people may not intimately familiar with the experience of liv- not be able to do? What evidence do I have to ing with a disability. support my views? Regardless of other people’s perception and • Are there specific life experiences or situa- view of disability and what it means to live with tions that influence how I personally or pro- a disability, disability is an experience that can fessionally view the phenomenon of disability positively or negatively influence how people and/or persons with disabilities? view themselves (Dunn, 2015). People who view • How do these beliefs and expectations influ- the presence of disability as negative may be ence the interactions I have with people, the challenged in how they perceive themselves therapeutic relationship, and/or the behavioral because of the disability itself and what the dis- health services I offer? ability means to them (Smart, 2009; Stuntzner, • What areas, if any, might I consider exploring 2015b). In these instances, people may view and expanding to improve the therapeutic alli- themselves as the disability or as a person whose ance I develop with the people I serve? life is consumed with the presence of a disability (Dunn, 2015) (see Fig. 16.1). When this happens, Examining our own beliefs and expectations people may refer to themselves according to what is important because without getting in touch they cannot do or as the disability or condition with our own thoughts, feelings, and experiences, itself rather than as people who have a full life clinicians may unintentionally alienate them- filled with many interests and abilities of which selves from the people they are trying to serve living with a disability is only one component and may promote additional barriers as a part of (Stuntzner, 2012; Wright, 1983). It is these indi- the therapeutic relationship. Compounding this viduals who may come in for help because they situation is the notion that people with disabili- do not know yet how to “right size” their disabil- ties “sense” and know when they are uncondi- ity. When we speak of “right size” we are refer- tionally accepted by others and when they are ring to the ability to acknowledge and accept they not. Much of this is due to the reality that people, have a disability, but instead of the disability regardless of disability type, are surrounded by being their whole existence, it is one piece of inaccurate societal attitudes, expectations, and bias (Smart, 2009), and throughout the process of living with a disability, they learn to recognize “the face” of this and what it looks like in others (Stuntzner et al., 2018).

Exploring a Person’s Disability Identity and Self-Concept A key component of coping with a disability is D about an individual’s identity and self-concept. When people live with a disability, persons without a disability frequently think that dealing with the disability is the person’s primary focus and identity. Part of this phenomenon can be understood since disability is a term that conjures up Fig. 16.1 Disability as the person’s whole identity 216 S. Stuntzner and J. A. Dalton them along with many other features and charac- tity has on their life (Dunn & Burcaw, 2013). teristics (Stuntzner, 2012). People who identify with the concept “disability Beyond the negative perception of disability pride” are those individuals who accept them- are the positive views and self-concepts. While is selves as they are and who do not feel a need to it not a given that all people reach a place of be “fixed” according to society’s standards. Many acceptance with their disability, many do eventu- such individuals describe the experience of living ally learn how to accept the disability and the with a disability as something they would not associated changes that accompany it. Behavioral change if given a choice because the disability health professionals working with people on has made them a better person and they fully adjustment and disability issues are encouraged embrace the person they are. Furthermore, peo- to help people explore ways to “right size” their ple who subscribe to this way of life feel they do disability and to assist them in viewing disability not need to eradicate the disability and that it is as an integrated part of who they are. Such a view society that needs to change and to be more is empowering as it provides people with the per- accepting, inclusive, and less stigmatizing and sonal space to acknowledge and honor the pres- inaccessible. ence of a disability as well as create room for Related to positive self-concept is the role other parts of their being and personhood (i.e., disability has in relation to personal growth. As personal traits, familial roles, life experiences, previously indicated, several people with a dis- career/employment; Stuntzner, 2012, p. 135). ability positively adjust to the disability and its From this perspective, people learn to see their associated changes. Professionals seeking to disability as only piece of who they are rather understand how this can be the case may find it than the sole focus of their identity (see Fig. 16.2; helpful to understand that people often describe Stuntzner, 2012). People who view the disability disability as an experience that helped them as an integrated piece of themselves and their learn and grow as a person and, in some instances, lives understand that they have more to them- become a better and more evolved, caring, and selves than the disability. Furthermore, many compassionate person compared to who they come to understand the importance and value of were before the disability (Park, 2010). For disability pride and the positive role such an iden- many people, disability is an experience that helps them:

(a) transcend and rise above their disability Disability Interests (Vash, 2003); (b) find a higher purpose in life; (c) develop internal strength and resilience; (d) make positive changes such as learning to Experiences Family forgive, improve coping skills, and become more compassionate and self-compassionate Values/Beliefs Career (Stuntzner & Hartley, 2014c); (e) enhance their sense of spirituality and develop a closer relationship to God (Glover- Culture/ Gender Graf, Marini, Baker, & Buck, 2007); Ethnicity (f) discover ways to use their situation to help others; (g) develop a greater appreciation for life; and Fig. 16.2 Self-identification chart. (Source: Stuntzner (h) strengthen personal and familial 2012) relationships. 16 Behavioral Health and Disability 217

Personal and Societal Barriers offense that is taking place. Some attitudinal bar- Experienced by Persons riers may seem trite and often take the form a with Disabilities microaggression. Common microaggressions experienced by persons with disabilities may People with disabilities experience a number of include being told how bad their situation is or personal and societal barriers. Numerous barriers looks, that someone could never deal with the accompany disability and have been a part of situation like they do, or by being belittled or society and interpersonal interactions throughout mimicked by another person (Lu, 2016). the history of our nation and as an integrated part Earlier, we discussed the importance of lan- of cultures for a number of centuries. Such treat- guage, expectations, and personal/professional ment and experiences are well-documented beliefs about the capabilities of people with dis- throughout the history of our nation as persons abilities. This topic, although challenging for with disabilities have a long history of being mis- some professionals to examine and honestly eval- treated, misunderstood, perceived as less than or uate, is imperative as it is these actions and beliefs as not capable, viewed differently, and being sep- that contribute to the issue of societal and attitu- arated or socially isolated (see Rubin & Roessler, dinal barriers when left unchecked and uncor- 2008). Despite this long lineage of misunder- rected. Furthermore, the phenomenon of societal standing and mistreatment, progress has been and attitudinal barriers are real and valid even if made to better understand disability and the professionals cannot see them or have not wit- needs of people with disabilities. However, soci- nessed them throughout their own life (Stuntzner ety and the professionals who work with this & Hartley, 2014a). Understanding the power all group of people are not where they need to be in of these barriers have on people with disabilities fully addressing and removing the barriers peo- is essential as they can affect how people view ple encounter especially given the fact that such themselves, their worth, and their ability to cope barriers are still heavily imbedded into our soci- and adapt to the disability and its associated ety and into the lives of people with disabilities. changes. Behavioral health professionals working with Personal barriers are another area of impor- persons with disabilities can enhance their tance for behavioral health professionals to knowledge and effectiveness by understanding address. Personal barriers can be understood as the complexity and multifaceted nature of those related to a person’s self-concept, beliefs disability-related barriers. Well-known barriers about oneself and the disability, negative thoughts encountered by people with disabilities include and feelings (i.e., depression, anxiety), locus of those that can be categorized as societal, attitudi- control and feelings of empowerment, level of nal (i.e., stigma, perceptions as a second-class independence, family support or lack thereof, citizen), architectural, environmental (i.e., lack of changes in relationships and friendships, and access to a building), medical, poor health insur- ability to self-advocate. ance coverage, employment (i.e., employer’s beliefs about disability), lack of access to services and community activities, and personal, Adjustment Is a Multifaceted just to name a few (Stuntzner & Hartley, 2014a). Process Of particular importance are societal and attitudinal barriers as these are the number 1 offensive Adjustment to disability is an area of importance and most difficult barriers to deal with as reported and relevance to persons with disabilities that by persons with disabilities (Vash, 2003). encompasses many facets. Clinicians striving to Attitudinal barriers are difficult because people understand adjustment and its relationship to dis- may not be able to prove they happened. ability are encouraged to learn about the numer- Similarly, attitudinal barriers appear ambiguous ous issues people face related to coping and to the person who is trying to help others see the adaptation (i.e., unemployment, attitudinal 218 S. Stuntzner and J. A. Dalton

barriers, self-identity), beyond what is covered in Beyond the mental, emotional, and changes in this chapter, as well as those that extend beyond coping aspects are those related to people’s daily the disability. While some of these are mentioned functioning and overall quality of life. Within this as a part of this chapter, the sheer volume and context, adjustment can be understood as the abil- complexity of these issues are more extensive ity to navigate the physical environment, be mobile than what can be covered in a chapter. Thus, clini- and function as independently as possible, become cians are also encouraged to familiarize them- employed or engaged with important personal life selves with the various factors that are associated goals, and achieve a well-sustained quality of life. with positive coping and adaptation and variations In short, successful adjustment to disability is in the needs of individuals living with a disability about learning to cope with the disability and any versus those of family members. Understanding associated changes in functioning and being an all of these pieces of adjustment are vital as they individual who is well integrated into society and can assist clinicians in understanding the experi- who is pursuing meaningful life goals (Livneh & ence of disability within a broader context, con- Antonak, 1997). Achieving these goals may seem ceptualizing the process of adjustment, and simplistic and realistic, but for many reaching such implementing therapeutic approaches and tech- dreams and aspirations is challenging due to the niques to meet the needs of the people they serve. continued existence of societal barriers, attitudes, and inadequate resources available to help them do so. The last point is of utmost importance because Adjustment to Disability some people need additional external resources and services to overcome such barriers, to be fully Adjustment to disability is often viewed as a per- integrated, and to complete the goals and dreams son’s ability to positively cope with the disability they aspire to achieve. and its associated disability-related changes (i.e., physical functioning, relationship changes, social support, self-concept, negative societal attitudes) Factors Associated with Adjustment (Marini & Stebnicki, 2012). Such a perception is to Disability understood; however, this view resembles only one goal of adjustment. In reality, adjustment is Numerous factors, well known by many rehabili- more inclusive than the thoughts, feelings, and tation scholars and practitioners, are associated behaviors people experience while learning to with coping and adjustment to disability and dis- cope with the disability and the changes it brings. cussed extensively throughout the literature. A review of the literature helps us understand that Factors associated with adjustment to disability people who adjust to disability experience a include those related to a person’s thoughts, feel- reduction of negative outcomes as well as an ings, perceptions, self-identity, personal experi- increase in more positive ones. More specifically, ences, disability and the situations surrounding the better adjusted people are the less likely to be the disability, supports or lack thereof, culture, self-critical and experience negative feelings, resources, and the external environment. Specific stress, depression, anxiety, or social isolation and examples of these areas can be understood and often report a less negative view of self (Marini & categorized as listed below (de Roon-Casssini, de Stebnicki, 2012; Stuntzner, 2008). As far as posi- St. Aubin, Valvano, Hasting, & Horn, 2009; tive attributes, adjustment to disability can help Enright, 2015; Johnstone & Yoon, 2009; Livneh, people be more self-compassionate, develop a 2000; Livneh & Antonak, 1997; Martz & Livneh, better self-image, forgive oneself and others, 2007; Nosek & Hughes, 2003; Smart, 2009; become more resilient, access coping skills, pos- Stuntzner, 2008; Trieschmann, 1988; Vash, 2003; sibly improve their health and functioning, have a Webb, Toussaint, Kalpakjian, & Tate, 2010; better outlook on life, and find purpose and White, Driver, & Warren, 2008, 2010; Willmering, meaning, just to name a few. 1999; Wright, 1983): 16 Behavioral Health and Disability 219

(a) Thoughts and beliefs—locus of control, self- Following the advent or diagnosis of disability, blame or cause of disability, perception of behavioral health services become geared disability as positive or negative towards the needs of the individual and some- (b) Feelings—negative feelings, anger, depres- times at the expense of the family. Focusing on sion, anxiety, self-empowerment the specific needs of persons with disabilities is (c) Self-identity—self-esteem, self-concept important and necessary; however, consideration (d) Personal experiences—gender, familial of the family and how the presence of a disability expectations affects the family is also of value. (e) Disability and associated situations—age of Because disability is an experience that onset, type of disability, cause of disability, affects both parties, it is plausible that the per- stability of the disability, visibility of the dis- son with the disability and the family have dif- ability, amount of stigma associated with the ferent needs and priorities as well as coping and disability, perceived meaning of disability adaptation responses to the disability. (f) Supports—spirituality, familial support, Ultimately, it is our hope that both the person friendships and relationships, social support with a disability and the family learn to accept (g) Culture—cultural views within family or eth- the disability and its associated changes. nic heritage Sometimes this happens, but sometimes it does (h) Resources—employment, education, socio- not. One example of this coping disparity is economic status, financial well-being, health when the person living with a disability learns insurance, coping skills (i.e., forgiveness, to cope and adjust to the disability and its asso- resilience) ciated changes but the family does not. As clini- (i) External environment—societal attitudes cians, we may see this when the individual is (i.e., strangers, employers), low expectations moving forward with one’s life in positive ways of persons with disabilities, environmental while the family is still dealing with feelings of barriers grief and loss or is still living in the past and can only see the family member with a disability as Specific factors most relevant to the people we the way he or she used to be. Another possible serve are likely to vary from person to person and scenario is evident in situations where the fam- situation to situation due to the fact that adjust- ily member with a disability views him- or her- ment to disability is an individualized process self as a lovable individual and as an acceptable (Livneh & Antonak, 1997). Similarly, it is the child of God or as a member of a spiritual and fact that no two individuals with disabilities, even religious organization while the family views those with the same disability, diagnosis, or level the person’s disability as a curse, or some sort of of functioning will adjust to the disability and punishment. Negative views as such work their their set of circumstances the same, nor will they way into family interactions and can have a necessary rely on the same identified factors to harmful impact on the person’s self-concept and help them adjust to the disability. For this reason, coping process. it is essential that clinicians familiarize them- Due to the varying needs and coping processes selves with as many of these factors as possible which are separate but somewhat intertwined, and to consider them on an individualized case- clinicians working with persons with disabilities by-case basis through a holistic lens of what is may find it helpful to consider and reflect on the most relevant to the person. needs of the person versus those of the family and ways the two may influence one another and the coping process. Figure 16.3 depicts a process Individual Versus Family Coping model of coping with the initial advent or discovery of disability for both the person with a Disability is an experience that forever changes disability and the family or individual family the life of the person and family members. members (Stuntzner, 2015b). 220 S. Stuntzner and J. A. Dalton

Person Family & with Individual Disability Similar Members Experiences

Disability

Coping/Questions

Beliefs & Feelings

Different Different Experiences Experiences

Rehabilitation & Emotional Support Adaptation Crisis Monitoring Redefining self Possible Overlap Medical Insurance Social & Environmental Financial Stigma Stability/Long Term Planning Empowerment & Advocacy Family Roles

Personal Self -Care** Independence

Fig. 16.3 Process model: the individual versus the family. (Source: Stuntzner 2015b)

The process model illustrates that both parties develop a new self-concept and self-identity, may have similar concerns and issues they are work on strategies to deal with societal and envi- working through, initially, while also trying to ronmental bias and stigma, learn how to self- address separate ones as a part of the coping pro- advocate, and explore levels of improved cess. According to this model, both the person functioning and independence. While these may with a disability and the family may have ques- not be the only areas the person is trying to tions, concerns, and personal beliefs or reactions address, it gives us some idea of the complexity to the disability they are trying to deal with as a of issues that may be taking place simultaneously part of the adjustment process. Having said that, or as a part of the adjustment process. the ways both parties respond to the disability While the individual with a disability is trying may differ the same as varying issues may be of to make sense of the disability and his or her new primary importance to either group at any given set of experiences, the family and individual time. More specifically, the person with disability family members are also going through their own may be trying to understand and cope with the coping process. Examples of their coping pro- disability, participate in therapy or rehabilitation, cess might include (a) seeking out resources for 16 Behavioral Health and Disability 221 emotional support and coping, (b) managing the nicians working with persons with disabilities are existence of a disability which may include crisis encouraged to consider both the individual’s management, (c) issues concerning finances and view and experience with a disability as well as payment of medical/treatment services, (d) finan- the family’s particularly given the fact that either cial and bill planning, (e) changes in family roles, one has the potential to positively and negatively and (f) access to self-care support. Because the influence the other. family is often involved with activities pertaining to keeping the family afloat emotionally, functionally, and financially, issues such as learning Therapeutic Techniques to Help to positively cope and adjust to the disability or People Move Forward practicing good self-care are often relegated to the bottom of the priority list. As a result, fami- Given the complexity of living and coping with a lies and individual family members may not be disability, it is imperative for behavioral health getting the support and assistance they need to clinicians to have a number of therapeutic tech- accept and move past the disability. When this niques at their disposal. Some of the approaches happens, the family’s negative coping style may clinicians use may be tied to specific theoretical inadvertently affect the coping process of the approaches while others may not. Many of the person with a disability. Helping the family counseling theories taught as a part of counsel- access behavioral health services is important as ing, psychology, or social work programs can be some may need support to deal with their own used to help people with disabilities. feelings of loss or change. For instance, some Theories that help people get in touch with families experience (Stuntzner, 2015b) the their thoughts, feelings, and behaviors and that following: can help people find meaning in their experience are of particular value. For example, the use of (a) loss of the person they used to know; person-centered therapy, behavioral therapy, cog- (b) grief and loss tied to presence of a nitive behavioral therapy, rational emotive ther- disability; apy, reality therapy, and existential therapy are (c) changes in familial and personal relevant to the needs and issues experienced by relationships; persons with disabilities (Chan, Berven, & (d) stress and difficulties associated with Thomas, 2004, 2015). In addition, the possibili- caregiving; ties offered under the third wave of behavior (e) alteration or loss of intimacy and therapy [i.e., dialectical behavioral therapy companionship; (DBT), mindfulness-based stress reduction (f) changes in social support due to having a (MBSR), mindfulness-based cognitive therapy family member with a disability; (MBCT), acceptance commitment therapy (g) changed or lowered expectations of the fam- (ACT)] are particularly exciting (Corey, 2009). ily member with a disability; and Such approaches help us understand how newer (h) alteration of personal hopes and dreams for therapeutic approaches such as mindfulness and their loved one and family. self-compassion can be incorporated into the therapeutic relationship. Clinicians conducting Family support is vital to successful coping work around the family may want to consider and adjustment. Families that receive the neces- Adlerian therapy or family systemic therapies as sary support and services are in a position to bet- frameworks to help conceptualize what is taking ter help themselves heal, learn ways to reorganize place. their lives and perceptions of disability so they Beyond the theoretical approaches are con- are positive and more affirming, and assist the cepts and techniques that can be used as a part of family member with a disability in moving for- a counseling framework or as a standalone pro- ward in a positive fashion. For these reasons, cli- cess. Those covered as a part of this section (i.e., 222 S. Stuntzner and J. A. Dalton forgiveness, self-compassion, resilience) have a strong history of empirical evidence to support their value as healing agents and are definitely relevant to the needs of people with disabilities. Self- Forgiveness Each of these can be used as a set of skills, a pro- compassion cess learned, or as an integrated component of another strategy. Furthermore, each one is effective in helping people “reduce thoughts (e.g., mental rumination, self-judgment, critical think- Resilience ing) and feelings (i.e., anger, anxiety, depression), and decrease fears as well as negative psychological reactions to disability” (Stuntzner et al., 2018, p. 49). The authors further explain that forgiveness, self-compassion, and resilience Fig. 16.4 Interconnection of forgiveness, self- can help people feel less socially isolated, be compassion, and resilience. (Source: Diagram from more connected to others, emotionally heal, Stuntzner, Dalton, et al. 2017) increase self-esteem, become more hopeful, learn to be kinder and more accepting of themselves, and in the end be more resilient—all of which are mendation is to work with each person individu- important when learning to deal with and move ally and to explore with them on a case-by-case past a disability. basis about which area they are most open to or Having specific tools and techniques is one feel is most relevant. All three areas are typically area of consideration, but perhaps larger ques- a learning and educational process and require tions and ones that are not always clear is that of work to become familiar with the practice of each where to start or which area is most relevant to skill within a person’s life; therefore, it is essential the person’s particular needs. Does a clinician for clinicians to get a feel for the amount of readi- begin with forgiveness, self-compassion, or resil- ness and willingness a person has to complete ience? Which of these three is most relevant work in each of these areas. given the person’s presenting issues and specific Clinicians wanting to learn more about each of needs? Or how does a clinician start in one area these components are encouraged to learn as and transition to another? (Stuntzner et al., 2018). much as they can about each one, what each term Clinicians wanting to better understand the means, and how they relate to people with dis- therapeutic value and interconnectivity of these abilities and the issues they encounter as well as three skills are encouraged to try to conceptualize become familiar with resources that are available. them according to model called, “therapeutic triad One such resource is a two-part counseling pod- of disability” developed by Stuntzner, Dalton, and cast produced by Mike Shook for The Thoughtful MacDonald (2017). The therapeutic triad of dis- Counselor. This two-part podcast is entitled, “The ability is a model comprised of three components: Therapeutic Triad: Forgiveness, Self-compassion, forgiveness, self-compassion, and resilience. and Resilience.” Throughout, clinicians are Each of these areas is viewed as distinct skills and exposed to information pertaining to the defini- processes by themselves but also as portals to the tion of disability; the interconnection between other two. In other words, therapeutic work in one forgiveness, self-compassion, resilience, and dis- area may lead to work in another as these three ability; and an overview of forgiveness, self-com- areas often overlap and are intersected (see passion, and resilience and their interconnection Fig. 16.4). Similarly, each of these areas are likely to one another. Clinicians are also educated about to overlap and serve as portals or gateways to the some of the barriers and benefits on skill cultiva- other two. While some professionals may want tion when working with people with disabilities exact answers about where to start, our recom- as well as an understanding of how each of these 16 Behavioral Health and Disability 223 are related and relevant to persons with disabili- in many instances, injustices followed by a period ties and their specific needs (Shook, 2018a, of learning to reframe the event(s) and to view 2018b, February 17 and 21). Having a full under- them in a more constructive and balanced manner standing of the meaning of each term, their asso- (Berecz, 2001). ciated benefits and barriers as well as potential Clinicians wanting to learn more about the resources and interventions is helpful as it is our forgiveness process, interventions, and resources belief that the more familiar professionals are have a number of options from which to choose. with each one, the more comfortable they will be Those who are new to the concept of forgiveness in applying them to their own life and in their as a therapeutic tool and process are encouraged work with the people they serve. to become familiar with the work of Dr. Robert Proceeding forward, it is important to recog- Enright, forgiveness scholar, at the University of nize that many excellent trainings, models, and Wisconsin–Madison. Enright, Freedman, and resources exist but most of them do not directly Rique (1998) developed a forgiveness process apply the concept or process to the experience of model comprised of 4 phases and 20 units. People living with a disability. Stuntzner and colleagues working through forgiveness according to this recognize this void and have worked to change framework are guided through the forgiveness this trend and to provide behavioral health clini- process and are exposed to the Uncovering cians and persons with disabilities resources and Phase, the Decision Phase, the Working Phase, interventions (i.e., see Stuntzner, 2014, 2015c, and the Outcome/Deepening Phase. Throughout 2016b, 2017; Stuntzner et al., 2018, 2019; this process, people learn to recognize their own Stuntzner & Hartley, 2014b, 2014c; Stuntzner & negative thoughts, feelings, behaviors, and obsta- MacDonald, 2016) that are specifically tailored cles to forgiveness. Following this recognition, to meet and address this population’s needs. In an many proceed to the Decision Phase where a effort to assist clinicians in being able to access decision is made to forgive. Once a commitment some of the available resources pertaining to for- is made to forgive, people begin to address the giveness, self-compassion, and resilience, a brief hurt and to work through it until they reach a definition and summary of each is provided. place of peace and healing. Such a model is not intended to be linear or a quick fix as these scholars understand that forgiveness exists on a con- Forgiveness tinuum ebbs and flows and, in many instances, takes time to occur. Forgiveness is a term defined somewhat differ- Clinicians interested in learning more about ently among forgiveness scholars. However, how forgiveness as a process is relevant to per- many of these definitions converge and are in sons with disabilities may want to consider a alignment with one another to understand that forgiveness model developed by Stuntzner et al. forgiveness is an individualized and personal pro- (2019). These scholars expand the information cess that is not necessarily linear or a one-time known about forgiveness and adjustment to dis- event. Forgiveness is also a process that occurs ability and integrate the two into a 6-phase, over time and requires intentional effort when a 23-unit forgiveness model. From this perspec- deep hurt or offense has been committed tive, forgiveness is also viewed as an educa- (Freedman, 2011). People who pursue and prac- tional process, one in which people have the tice forgiveness find they experience less fre- opportunity to: (a) examine their hurts and quent negative thoughts, feelings, and behaviors offense, (b) review their existing coping skills, and replace them with more positive qualities (c) explore the use of forgiveness and other ther- such as tolerance, patience, compassion, and apeutic options to aid in healing, (d) address any benevolence (Enright, 2015). Furthermore, for- barriers or obstacles that inhibit their ability to giveness is a means that allows people to con- forgive, (e) learn about forgiveness and its rele- front their emotional and psychological pain and, vance to peoples’ lives, and (f) cultivate and 224 S. Stuntzner and J. A. Dalton integrate forgiveness skills. Similar to Enright’s Self-Compassion model, forgiveness is viewed as a process and as one that is not necessarily linear. Additionally, Self-compassion is a relatively new concept due to the nature of forgiveness being difficult within our Westernized culture and as an inte- and not easy for some to consider, it is antici- grated component of behavioral health practices. pated that a certain amount of forgiveness edu- Thanks to the founding efforts of self-compassion cation and learning regarding the ways research scholar, Dr. Kristin Neff at the University forgiveness can help people heal and move for- of Texas–Austin, and other self-compassion ward can be of help. experts (i.e., Christopher Germer, Paul Gilbert), Knowing where to start or what resources to self-compassion has emerged as an essential use can be a daunting process, particularly for therapeutic tool within the counseling, psychol- clinicians who are unfamiliar with the use and ogy, and allied helping professions. integration of forgiveness as a part of profes- Self-compassion is often described as the abil- sional practice. As previously mentioned, there ity to accept oneself, fully, despite a person’s are a number of resources clinicians can use to imperfections and flaws and to treat oneself with assist them with forgiveness work among the kindness, gentleness, and warmth the same was people they serve. Applied resources and inter- we would offer such traits to another person (Neff, ventions that may be of use to consider include 2012) especially towards a person experiencing the work of Enright (2001), Stuntzner (2014), pain or hurt. While such a behavior may appear and Tutu and Tutu (2014). Enright’s (2001) pro- simplistic, the opposite is often true. Some of this cess model is displayed in a book entitled, is related to the fact that self-compassion is an “Forgiveness is a Choice: A Step-by-Step Eastern, Buddhist philosophy and way of life, not Process for Resolving Anger and Restoring a traditional Westernized value. Instead, many of Hope.” Throughout this book, readers are guided us may have been reared to value the extension of through the forgiveness process in a step-by-step compassion towards others but not towards our- fashion. Stuntzner (2014) offers clinicians expo- selves. Those that do have sometimes been sure to a forgiveness intervention that is specifi- described as weak or lazy because they are per- cally geared towards people with disabilities and ceived by outsiders—people who do not under- to the experience of disability. In this interven- stand the value of self-compassion—as individuals tion, people proceed through seven modules. who are somehow not owning their pain. People learn about forgiveness, its applicability Despite these historical negative views, soci- to disability, barriers to forgiveness cultivation, ety and helping professions are beginning to forgiveness and disability in relation to gender, understand the power and value of self- impact of forgiving versus not forgiving, being compassion (Neff, 2018a; Neff & Germer, ready to forgive, strategies to promote forgive- 2018). More specifically, self-compassion ness, and ways to continue the forgiveness work research helps us clearly see that self-compas- started. Finally, Tutu and Tutu (2014) wrote a sion is a healthy, personal skill that holds many book entitled, “The Book of Forgiving,” which healing qualities and can be used to help improve also covers many important concepts related and our life and our relationship with ourselves. In relevant to the forgiveness process. Tutu and short, it is through the practice and integration Tutu help the reader understand why forgiveness of self-compassion that people are able to is important, differentiate between what forgive- decrease negative thoughts and feelings (i.e., ness is and is not, and get in touch with the anxiety, depression; Leary, Tate, Adams, Allen, importance of telling one’s story and in under- & Hancock, 2007; Neff, 2003; Neff, Kirkpatrick, standing the hurt. These authors also help us & Rude, 2007), stress, self-criticism (Neff, understand the importance of needing forgive- 2003; Neff, Kirkpatrick, et al., 2007), and self- ness, forgiving ourselves, and applying forgive- blame (Terry & Leary, 2011). Furthermore, self- ness to our external world. compassion has the ability to promote positive 16 Behavioral Health and Disability 225 qualities, some of which include greater life sat- (Neff, 2011), (d) The Clinician’s Guide to isfaction (Neff, 2003), feeling more socially Teaching Mindfulness: The Comprehensive connected (Neff, 2003), optimistic outlook on Session-by-Session Program for Mental health life (Neff, Rude, & Kirkpatrick, 2007), feeling Professionals and Health Care Providers (Wolf more motivated (Neff, Rude, et al., 2007), & Serpa, 2015), and (e) The Power of Self- becoming more resilient (Leary et al., 2007; compassion (Welford, 2013). Neff, Hsieh, & Djitterat, 2005), and forgiveness (Neff & Pommier, 2012), just to name a few. Similar to forgiveness, learning to be self- Resilience compassionate is an active and intentional process. While some people may be born with a Resilience is another term that is not consistently higher ability to be kind and loving towards one- defined. Perhaps, the most common description self, self-compassion is a skill that ebbs and flows of resilience are those that refer to a person’s throughout a person’s life and is strengthened ability to “bounce back or overcome some sort of with intentional practice. Clinicians wanting to difficult life event or adversity despite the odds” learn more about self-compassion have a number (Edhe, 2009) which may include the presence or of resources at their disposal. advent of a disability. Some scholars describe Resources include active workshops and resilience as a trait that once acquired helps peo- self-compassion trainings some of which can be ple to grow exponentially and to become stronger accessed and viewed on Dr. Neff’s self- or better at dealing with the challenges life throws compassion website (i.e., http://self-compas- at them (Neenan & Dryden, 2012). In recent sion.org/). Self-compassion workshops offered years, several scholars stress the fact that people include both those that are short and more time do not have to be born resilient to succeed in intensive. Specific trainings that may be of overcoming difficult life events; instead, many interest to some clinicians are the Mindful Self- believe that resilience can be taught, enhanced, Compassion (MSC) Intensive trainings and the and further developed with purposeful intention MSC Teacher trainings. A second helpful fea- and effort (Deshields, Heiland, Kracen, & Dua, ture from both a research and a practical stand- 2016; White et al., 2008, 2010). Recognizing this point is Neff’s (2018b) self-compassion scale fact is good news and provides people with much (see http://self-compassion.org/test-how-self- hope as they move forward. For many, resilience compassionate-you-are/) that measures how and resilience skill cultivation becomes a gate- self-compassionate a person is. Such a tool can way to healing and a portal to other areas of be instrumental in helping people recognize change, previously unseen (Stuntzner & their current level of self-compassion or lack MacDonald, 2014a, 2014b). thereof and can be integrated into the therapeu- Resilience is a concept relevant to the needs tic relationship as a means to begin the discus- and experiences of persons with disabilities. As sion and exploration of self-compassion. mentioned earlier, when disability occurs people Knowledge and understanding of self-are faced with a number of changes. In short, dis- compassion and its role in therapy can be under- ability is an experience where people have to learn stood by accessing the number of books and about the disability and the associated changes that resources that are beginning to emerge. Resources accompany it along with the multiple barriers and that appear to have an applied context and may be obstacles that often accompany it (i.e., low expec- of interest to clinicians include the following: (a) tations, poor and inadequate societal attitudes, One Minute Mindfulness (Altman, 2011), (b) The unemployment, bias). Some people may not be Self-Compassion Skills Workbook: A 14-day Plan aware or prepared for these changes and experi- to Transform Your Relationship with Yourself ences, particularly given the fact that many parts of (Desmond, 2017), (c) Self-compassion: Stop living with a disability are still not openly dis- Beating Yourself Up and Leave Insecurity Behind cussed (Stuntzner et al., 2018). 226 S. Stuntzner and J. A. Dalton

With the growing awareness of resilience and resilience course had practical and relevant con- the role it plays in peoples’ lives is an increase in tent which could be used in the work they do. resources, education, and training pertaining to More specifically, 97% found the explanations of this topic. Yet, resilience and resilience cultiva- resilience, self-compassion, and forgiveness of tion is an area that remains minimally recognized value, 91% reported the applied learning activi- and applied to persons with disabilities. In an ties to be useful, and 93% reported the learning effort to address this void and need within the activities as appropriate and helpful in learning helping professions, Stuntzner and colleagues and applying the various concepts. Furthermore, developed an online course for counselors and the data gathered by CRCC supported the fact allied helping professionals (Stuntzner, 2016a, that the activities and content delivered through- 2016b), a ten-module resilience intervention for out the course helped professionals construct persons with disabilities (Stuntzner & Hartley, various strategies they could use to cultivate and 2014a, 2014b), and provide trainings to profes- enhance resilience among themselves and the sionals (Stuntzner, MacDonald, & Dalton, 2017) people they serve. on this subject matter. A second available resource that is specifi- The online resilience course is entitled, cally geared towards the needs and issues of per- Resilience and Disability: Enhancing sons with disabilities is Stuntzner and Hartley’s Rehabilitation Professionals’ Understanding and (2014a, 2014b) resilience intervention. The resil- Application of Resilience to Rehabilitation ience intervention is comprised of ten modules, Counseling, and is a part of the Commission of each consisting of resilience-based skills and Rehabilitation Counselor Certificationdelivered in a format so that each module builds e-university program. Professionals who take the upon the other. Resilience skills covered include: course are afforded the opportunity to learn about an overview of resilience and its applicability to resilience and its applicability to persons with persons with disabilities, attitude and outlook on disabilities (Unit 1), benefits and barriers of resil- life, locus of control, regulation of thoughts and ience cultivation (Unit 2), and factors associated feelings, coping skills, spirituality and forgive- with resilience and examples of how these are ness, compassion and self-compassion, growth applicable and relevant to persons with disabili- and transcendence, and social and family sup- ties (Units 3–6). In Unit 7, the final unit, profes- port. The intervention concludes with a review of sionals have an extended opportunity to apply the the skills learned and opportunities for reflection information learned and reflect on how they about how people may continue to use and would integrate the content learned into their pro- enhance the skills learned in their journey to fessional practice. Clinicians completing the pro- become more resilient and how these may be gram receive 13 CEUs. used and further enhanced. According to the data collected by the Furthermore, as a part of the intervention, Commission on Rehabilitation Counselor Stuntzner and MacDonald (2014a, 2014b) con- Certification e-university program, professionals ducted two pilot studies among persons with who completed the aforementioned resilience various disabilities. Findings from these studies course were asked to evaluate the course’s demonstrated a significant decrease in partici- strength, applicability, and relevance to their role pants’ anxiety and depression, an increase in for- as professionals and to the work they do with giveness and resilience, and changes in various individuals with disabilities. Preliminary data is phases of adjustment to disability. comprised of feedback from 100 rehabilitation A third option for clinicians to expand their counseling professionals who completed the knowledge and understanding of resilience is that course. Course participants to date range from of self-exploration which may include increasing the new counselor to those who are more sea- one’s knowledge through reading or professional soned (i.e., 0–35 years of experience). Among trainings. Some suggested resources that can be these 100 participants, majority reported that the accessed to help professionals include the follow- 16 Behavioral Health and Disability 227 ing books: (a) The Resilience Break-Through: 27 abilities in a holistic manner, not as the Tools for Turning Adversity into Action (Moore, disability (Stuntzner, 2012). 2014), (b) Chronic Resilience: 10 Sanity-Saving • Most people with a disability do not view Strategies for Women Coping with the Stress of themselves as the disability. Illness (Horn, 2013), (c) The Woman’s Book of • No two people view a disability the same, nor Resilience: 12 Qualities to Cultivate Resilience do they cope the same based on similar dis- (Miller, 2005), (d) Reflections from the Past: Life abilities (Livneh & Antonak, 1997). Lessons for Better Living (Stuntzner, 2014), and • Adjustment to disability is complex and is (e) The Resilience Factor: 7 Keys to Finding Your about much more than adjusting to the Inner Strength and Overcoming Life’s Hurdles disability; adjustment is comprised of many (Reivich & Shatte, 2002). components and influenced by several factors. • Disability is an experience that influences the individual as well as the family. Concluding Thoughts • Emerging techniques such as forgiveness, self-compassion, and resilience are important Disability is an experience that forever changes a components of helping people move forward person’s life and that of one’s family. While many following a disability. people learn to cope with the disability and its associated changes, adjustment and moving past Content covered throughout is intended to the disability is a process: one that takes time and serve as a starting basis in learning about disabil- support. Clinicians working with this population ity and the needs of persons with disabilities. are in a position to assist people with this process Clinicians desiring to learn more about this group and in creating the life they seek. Furthermore, of individuals are encouraged to continue their disability is a life situation that affects many of us education and understanding as there is a lot to over the lifespan whether we consciously recog- know about the experience of disability and ways nize this or not, from birth to death. to enhance the services offered to and received by Disability statistics consistently support that persons with a disability. approximately one in five people (20%) live with a disability (US Census, 2010), making it the largest minority group in the USA. However, it is References a group of individuals that perhaps remains the least understood. In an effort to help change this Altman, D. (2011). 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Jessica R. Graham-LoPresti, Tahirah Abdullah, and Amber Calloway

Generalized Anxiety Disorder Psychiatric Association, 2013). This worry is accompanied by poor concentration, irritability, Similar to other anxiety disorders, generalized sleep disturbance, and physical symptoms, anxiety disorder (GAD) is characterized by fea- including muscle tension, restlessness, or feeling tures of excessive fear and related behavioral dis- keyed up or on edge. turbances. Specifically, GAD is characterized by Worry, along with these accompanying symp- a pattern of excessive worry that is pervasive and toms, cause clinically significant distress or spans a wide range of events and activities (DSM impairment across areas of psychosocial func- 5, American Psychiatric Association, 2013). For tioning. For example, generalized anxiety disor- example, adults with GAD may worry about der is associated with occupational impairment, financial matters, the quality of ongoing relation- including higher rates of unemployment, more ships, world affairs, their health and the health of days of missed work, and more frequent occur- loved ones, and everyday activities (e.g., job rence of inability to perform usual role function- responsibilities, being punctual, completion of ing activities (Henning, Turk, Mennin, & Fresco, household chores). Individuals with GAD worry 2007; Wittchen, 2002; Wittchen, Zhao, Kessler, more days than not for at least 6 months and find & Eaton, 1994). GAD accounts for 110 million it difficult to control the worry (DSM 5, American disability days per annum in the US population (Kessler et al., 2005; Merikangas et al., 2007). Thirty-seven percent of participants with GAD in the Epidemiological Catchment Area Study J. R. Graham-LoPresti (*) Department of Psychology, Suffolk University, were receiving some type of public assistance Boston, MA, USA with only about half of the total sample employed e-mail: [email protected] full time (Massion, Warshaw, & Keller, 1993). T. Abdullah Individuals with GAD also show functional Department of Psychology, Suffolk University, impairment in personal domains. Nearly one- Boston, MA, USA third of those with GAD (28%) report severe University of Massachusetts Boston, disability within their romantic relationships Boston, MA, USA (Henning et al., 2007). Specifically, GAD is A. Calloway associated with elevated rates of marital dis- The Penn Collaborative for CBT and Implementation tress, divorce, and separation (Leon, Portera, & Science, Suffolk University, Boston, MA, USA Weissman, 1995; Wittchen et al., 1994). GAD Philadelphia VA Medical Center, has also been linked to physical health prob- Philadelphia, PA, USA

© Springer Nature Switzerland AG 2020 231 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_17 232 J. R. Graham-LoPresti et al. lems, including coronary morbidity (Martens rates of GAD (Parkerson et al., 2015). DSM 5 et al., 2010) and cardiovascular mortality recommends that mental health providers take (Denollet et al., 2009; Phillips et al., 2009). In “cultural contextual factors into account” when fact, GAD is among the most prevalent mental making a diagnosis of any anxiety disorder. health conditions seen in primary care (Lieb, Prevalence of GAD has also been shown to Becker, & Altamura, 2005) and specialty clinics vary by immigration status. Generally, those who (Fogarty, Sharma, Chetty, & Culpepper, 2008; have immigrated tend to be at less risk of any Ormel et al., 1994; Schonfeld et al., 1997). GAD anxiety disorder compared to their American- alone is significantly related to greater disability born counterparts (Alegría et al., 2007; Breslau, than other anxiety disorders, pure alcohol and Borges, Hagar, Tancredi, & Gilman, 2009; drug use disorders, nicotine dependence, and Breslau & Chang, 2006; Takeuchi et al., 2007). personality disorders even after controlling for For GAD, ethnic minorities born outside the sociodemographics and any comorbid disorders USA exhibit lower lifetime prevalence rates as (Grant et al., 2005). Comorbidity increases the compared to their American-born counterparts impairment and severity of GAD (Judd et al., (Budhwani et al., 2015). 1998; Stein, 2001; Wittchen, 2002; Wittchen While ethnic minorities and immigrant popu- et al., 1994). lations are less likely to meet criteria for GAD, Generalized anxiety disorder is the most individuals in the LGBTQ population are more common of the anxiety disorders with an likely to meet criteria than heterosexual and cis- approximate 2.9% 12-month prevalence and gender men and women (Cochran, Sullivan, & 9% lifetime prevalence in the general popula- Mays, 2003). Transgender women have the high- tion in the USA. There has been increasing est prevalence of severe to extremely severe gen- examination into rates of GAD within margin- eralized anxiety symptoms followed by bisexual alized populations such as racial/ethnic and women, followed by lesbians. Transgender men sexual minorities as well as immigrant popula- exhibit the highest degree of anxiety followed by tions. Overall, racial and ethnic minority groups gay men and bisexual men (Smalley, Warren, & tend to meet criteria for lifetime GAD at a lower Barefoot, 2016). Additionally, higher odds of any rate as compared to White Americans lifetime anxiety disorder are more pronounced (Budhwani, Hearld, & Chavez-Yenter, 2015; among sexual minority men than among sexual Soto, Dawson-Andoh, & BeLue, 2011). In a minority women (Bostwick, Boyd, Hughes, & study evaluating prevalence rates of anxiety dis- McCabe, 2010). It has been suggested that the orders across ethnic groups in the USA, it was mental health disparities experienced by gender found that White Americans consistently or sexual minority populations are related to endorsed symptoms of GAD (8.6%) more fre- greater exposure to gender/sexual orientation- quently than African Americans (4.9%), related experiences of rejection, discrimination, Hispanic Americans (5.8%), and Asian harassment, and victimization (e.g., Bockting Americans (2.4%; Asnaani, Richey, Dimaite, et al., 2013; Effrig & Bieschke, 2011; Grant Hinton, & Hofmann, 2010). Asian Americans et al., 2006; Nuttbrock et al., 2013; Woodford, consistently endorsed symptoms of a range of Kulick, Sinco, & Hong, 2014). anxiety disorders less frequently than other ethnic groups. A similar pattern in the prevalence of GAD across ethnic groups has been observed Cultural Responsiveness in other large-scale epidemiological datasets and Competency (Grant et al., 2005, 2006). This pattern has been observed in older adults as well (Woodward Cultural competency and responsiveness are a et al., 2012). However, it has been suggested benchmark for ethical and effective clinical prac- that these differences could reflect cross-cul- tice which means that the implementation of tural measurement biases related to the diag- these practices throughout the different stages of nostic instrument rather than true differences in the assessment, diagnosis, and treatment of GAD 17 Culturally Responsive Assessment and Treatment of Generalized Anxiety Disorder 233 in traditionally underserved and marginalized approaches for GAD should be uniformly applied populations is crucial. It is important to consider across identities. Although this approach is the research highlighting significantly higher widely used, it may impose dominant group cul- rates of mental health treatment dropout and lack tural biases upon clients from traditionally mar- of access to quality, culturally competent care ginalized backgrounds (e.g., racial and ethnic for racial and ethnic minorities (Jackson et al., minorities, sexual minorities, gender minorities). 2007; Lester, Artz, Resick, & Young-Xu, 2010; More specifically, applying the approach of cul- Roberts, Gilman, Breslau, Breslau, & Koenen, tural universality during the therapeutic process 2011) as well as gender and sexual minorities can lead clinicians to fail to address unique expe- (Parameshwaran, Cockbain, Hillyard, & Price, riences (e.g., oppression, cultural and familial 2017) as compared to the general population. influences, identity-based trauma) that may con- Much of the literature surrounding barriers to tribute to the development, maintenance, and access to quality mental health care point to the expression of mental health difficulties. lack of cultural responsiveness of mental health- The emic approach to prevention, assessment, care systems and providers (Freimuth et al., diagnosis, and treatment challenges the assump- 2001; Snowden, 2001), for example, the history tions that mental health difficulties are of the same of misdiagnosis for clients of color, the experi- nature and development across cultures. This ence of racial macro- and microaggressions in approach suggests that culture and life contexts sig- the context of mental health treatment, lack of nificantly influence the manifestation, course, and familiarity of clinicians with common medical expression of mental health difficulties and, in turn, conditions associated with racial or ethnic group should influence the therapy process. The emic membership, and lack of access to evidence- approach to therapeutic processes is at the core of based practices or resources. Cultural compe- culturally responsive prevention, assessment, diag- tence and responsiveness is described as a nosis, and treatment and leads to a multidimensional clinician’s commitment to gaining awareness, model of identity development that includes indi- knowledge, and skills that can promote optimal vidual-, group-, and universal-level influences. functioning in clients presenting with varied clin- The first step in engaging in culturally respon- ical presentations as well as various intersecting sive assessment of GAD is developing awareness identities, with an understanding of the impact of of our own assumptions, values, attitudes, and societal and institutional systems (Sue & Sue, biases based on our intersecting identities and the 2004). In addition, a focus of culturally respon- intersecting identities of our clients. Hays (2008) sive assessment and treatments is the ability to presents an acronym, the ADDRESSING frame- understand clients’ cultural norms and values work that helps therapists attend to their own while also attending to clients’ unique experience identities and the identities and lived experiences within any identity category or cultural group. of clients. This framework focuses on nine cul- Theorists have described two different approaches tural factors that therapists should attend to in the to prevention, assessment, and intervention pro- context of the assessment, diagnosis, and treat- cesses, the etic and emic approaches, with the lat- ment of GAD: Age and generational influences, ter being a culturally responsive approach (Sue & Development disabilities, acquired Disabilities, Sue, 2004). The etic approach is the manner in Religion and spiritual orientation, Ethnicity and which therapy has been traditionally practiced. race, Socioeconomic status, Sexual orientation, This approach is housed within the theory of cul- Indigenous heritage, National origin (citizenship tural universality and assumes that approaches to and immigrant status), and Gender. See Fig. 17.1. therapeutic interventions are universal in nature. In addition, D’Andrea and Daniels (2001) Specifically, the etic approach maintains that psy- present the RESPECTFUL model of interview- chological disorders, like GAD, develop and ing. This model presents ten dimensions of iden- express similarly across cultures and prevention, tity including Religion/spirituality, Economic/ assessment, diagnostic, and intervention social class background, Sexual identity, Personal 234 J. R. Graham-LoPresti et al.

ADDRESSING DefinitionsClient InformationTherapist Information Age and generational influences Disability Status (Developmental and Acquired) Religion and Spiritual Orientation Ethnicity (and Race) Socioeconomic Status Sexual Orientation Indigenous Heritage National Origin and Generational Status Gender

Fig. 17.1 Addressing Framework (Hays, 2008) style and education, Ethic/racial identity, her identity, discrimination, and/or oppression Chronic/lifespan status and challenges, Trauma/ may be related to Anita’s mounting worry. By crisis, Family background and history, Unique opening the door for this conversation as the thera- physical characteristics, and Location of resi- pist, it signals to the client that it is important, and dence/language differences. See Fig. 17.2. appropriate, for them to discuss issues related to These models present a framework for thera- marginalization or discrimination as a part of their pists to engage in culturally responsive assessment therapy process. In Anita’s case, her mounting and treatment of GAD with diverse clients. An worry is related to her fears of deportation. example of culturally responsive assessment of Specifically, she worries that if she leaves her GAD can be seen in the case of Anita, a 25-year- home that she will come into contact with ICE (US old Mexican woman seeking therapy to discuss Immigration and Customs Enforcement) and be her mounting worry which is making it difficult detained and deported which would mean that she for her to leave her home. She reports having dif- would be separated from her husband and three ficulty falling asleep due to her worry which leads school-aged children indefinitely. This separation to 4 h of sleep per night and feelings of “exhaus- would also mean that her family would not have tion.” Anita reports worrying about her safety, financial stability and most likely end up home- ability to effectively do her job as a store manager less. It is difficult to develop an effective case con- because of struggles with concentration, the health ceptualization for the treatment of diverse clients and well-being of her children and husband, as experiencing GAD without the full context of their well as financial stability. An initial assessment of worry. Assessing for the intersection of mental Anita’s symptoms might find that she meets DSM health and identity contexts is of crucial impor- 5 diagnostic criteria for GAD in that she is report- tance as it relates to therapy engagement and ing significant worry about a number of aspects of retention for clients from traditionally marginal- her life more days than not, for 6 months, and ized backgrounds as well as effective development experiences fatigue, difficulty concentrating, and of case conceptualization and treatment plans. sleep disturbance. However, an initial assessment of symptoms and diagnosis of GAD for Anita would be missing a significant aspect of her anxi- Intervention ety. It is important for therapists to inquire about the connection between this young woman’s worry There are numerous models that explain the and her various identities. First, her therapist nature and the potential cause of GAD. For exam- should inquire about Anita’s racial and ethnic ple, cognitive avoidance theory posits that worry identity and explore the ways in which aspects of serves an avoidant function to diminish the nega- 17 Culturally Responsive Assessment and Treatment of Generalized Anxiety Disorder 235

10 Dimensions Identify yourself as What personal and How effective will a multicultural group strengths can you be with being. you develop for individuals who each multicultural differ from you? dimension? Religion/Spirituality Economic/social class Sexual identity Personal Style and Education Ethnic/Racial Identity Chronical/Lifespan status and challenges Trauma/Crisis Family Background and History Unique Physical Characteristics Location of Residence, Language Differences

Fig. 17.2 Respectful Model (D’Andrea & Daniels, 2001) tive emotional reactivity to perceived internal and physiological, affective, and behavioral responses. external threats (Borkovec, Alcaine, & Behar, Because each response influences the intensity of 2004). An acceptance-based model of GAD the other, learning to reduce physiological activa- builds on the cognitive avoidance theory and con- tion should also reduce activation in the other sys- ceptualizes anxiety as stemming from a maladap- tems and therefore reduce anxiety overall. The tive relationship with internal states, experiential treatment involves recognizing the early signs of avoidance, and behavioral constraint (Roemer & anxiety, learning and practicing relaxation skills, Orsillo, 2002). The intolerance of uncertainty and applying relaxation at the first sign of anxiety. model proposes that individuals with GAD find AR is one of the few empirically supported treat- uncertain or ambiguous situations to be “stressful ment for GAD (Chambless & Ollendick, 2001) and upsetting” (Dugas & Koerner, 2005, p. 62) and is consistently used as the gold standard and experience chronic worry in response to such against which newer treatments are compared. situations. These individuals believe that worry Cognitive behavioral therapy (CBT) for GAD, will help them to either prevent these feared based on the cognitive avoidance model (Borkovec events or cope with them if they occur. & Costello, 1993) has been shown to be superior These conceptual models of GAD have borne to the alternative treatments (e.g., placebo, psy- different psychological interventions. Applied chopharmacological, psychodynamic, supportive) relaxation (AR; Öst, 1987) is based on the premise or control in most cases (Borkovec & Ruscio, that anxiety involves the interaction of cognitive, 2001). CBT based on the intolerance of uncer- 236 J. R. Graham-LoPresti et al. tainty model has also been shown to be efficacious the experiences of marginalization that the client (Dugas et al., 2010; Gosselin, Ladouceur, Morin, has expressed experiencing strengthens the thera- Dugas, & Baillargeon, 2006; Ladouceur et al., peutic relationship and may also improve therapy 2000). However, CBT has the lowest average retention and outcomes. effect size for GAD, when compared to effect CR requires clients to identify the automatic sizes of CBT for other anxiety disorders (Brown, thoughts or images they have that are tied to their Barlow, & Liebowitz, 1994). An acceptance-based experience of anxiety. Therapists ask clients ques- behavioral treatment was developed with an tions to elicit identification of automatic thoughts attempt to improve these outcomes. ABBT com- and images. Clients must first be able to identify bines mindfulness- and acceptance-based strate- the automatic thoughts and images in order to gies with behavioral approaches. It focuses on evaluate their accuracy and usefulness (Wenzel acceptance or allowing the presence of internal et al., 2016). Therapists work with clients to eval- experiences while developing flexible behavioral uate their automatic thoughts related to situations repertoires that are consistent with the individual’s in which they experience anxiety through the use values (Orsillo & Roemer, 2011). ABBT has been of strategic questions such as, “What evidence do shown to be equally as effective as applied relax- you have for that?” “Might there be other expla- ation (Hayes-Skelton, Roemer, & Orsillo, 2013). nations for the situation?” and “How likely is it that the worst case scenario would occur? How bad would the worst case scenario be?” However, Cognitive Restructuring (CR) for clients whose anxiety is tied to their experiences of oppression or discrimination as a person Cognitive restructuring (CR) is a process with marginalized identities, questioning whether employed in cognitive and cognitive behavioral there may be other explanations for oppressive or therapy that involves identifying, evaluating, and discriminatory encounters is invalidating, is mar- modifying negative or limited thoughts (Wenzel, ginalizing, can exacerbate symptoms, and could Dobson, & Hays, 2016). At the core of CR for reduce clients’ likelihood of returning to therapy. GAD is the notion that one cause of the anxiety Instead of questioning the validity of these types individuals with GAD experience is faulty, irra- of encounters, culturally responsive therapists can tional, or distorted thinking and that learning to instead question the internalization of the oppres- notice these thoughts, evaluate their accuracy and sion or discrimination experienced (Graham, usefulness, and modify them will reduce anxiety Sorenson, & Hayes-Skelton, 2013). symptoms. Prior to beginning cognitive restruc- For example, the fictional client Kayla is a turing with a client, therapists provide informa- 26-year-old Black woman diagnosed with GAD tion about the process and provide a basis for who worries about a number of things in her life. using CR techniques. When introducing CR to She works at a law firm where she is the only clients, therapists take care to connect informa- Black lawyer. She has encountered a combination tion about CR and the basis for using it to clients’ of racism and sexism throughout her career and experiences. Therapists encourage clients to worries that she is perceived as less knowledge- “acknowledge all of the information that affects able and less competent than her counterparts and their life problems and to recognize that some of will not be able to earn a promotion at her firm those pieces might not be as negative as they are despite her hard work and success winning cases. concluding” (Wenzel et al., 2016, p. 91). For cul- These worries have made it difficult for Kayla to turally responsive clinicians, part of this intro- focus at work, and she often stays awake at night duction to CR may involve contextualizing worrying about whether she will be able to have a clients’ anxiety and recognizing that some life successful career. Kayla tells her therapist that problems related to marginalization and oppres- whenever she tries to share her concerns with col- sion are, in fact, as negative as the client is con- leagues, they are dismissive and tell her she has a cluding. Acknowledging and validating as real lot to be grateful for so she should not complain. 17 Culturally Responsive Assessment and Treatment of Generalized Anxiety Disorder 237

Recently, a new lawyer at the firm assumed she skills to relax in the moments following those was an administrative assistant and requested she early indicators of anxiety (Hayes-Skelton et al., copy some documents for him when she came to 2013; Öst, 1987). The basis of the theory under- his office to give him the file for a case they would lying AR is that the physiological, cognitive, be working on together. Kayla stated that her auto- affective, and behavioral responses associated matic thoughts in this situation were, “Here’s with GAD reinforce each other, resulting in another co-worker who thinks I’m just the help increased intensity of symptoms. Reducing the because I’m a Black woman” and “People will intensity of any single manifestation of the anxi- give him credit, and not me, for winning the case.” ety response will, in turn, reduce the intensity of Asking Kayla, “what evidence do you have for the other responses, so reducing the intensity of that?” or “might there be other explanations for the the physiological response will reduce the inten- situation?” would be incredibly invalidating. sity of the cognitive, affective, and behavioral Culturally responsive therapists “need to think manifestations of GAD. Similarly, abating one deeply about the ways they are teaching clients to aspect of the physiological response would abate restructure their thoughts and the implications of other physiological responses. Intervening early these decisions” (Graham et al., 2013, p. 105). in the anxiety cycle by using AR can prevent the Primarily, it is important for therapists to recognize anxiety response from intensifying and lead to a that clients with marginalized backgrounds may response pattern characterized by increased have experiences that have resulted in seemingly relaxation as opposed to intensified anxiety catastrophic, distorted thinking that actually is (Hayes-Skelton et al., 2013). AR consists of self- accurate and based in reality. In such cases, chal- observation skills; relaxation skills including lenging that experience or thoughts about that progressive relaxation, release-only relaxation, experience could be detrimental to the therapeutic cue-controlled relaxation, differential relaxation, relationship, could worsen symptoms, and could and rapid relaxation; and application training reduce the possibility of therapeutic gains (Graham (Öst, 1987). et al., 2013). Thus, instead of asking Kayla, “what evidence do you have for that?” or “might there be Culturally Responsive AR other explanations for the situation?” a more cul- As is often the case with culturally responsive turally responsive reply to her automatic thoughts practice, culturally responsive AR aligns with would be, “your automatic thoughts seem to reflect “good AR,” that is, general best practices for con- your real experiences of racism. I think it is impor- ducting an AR intervention. For example, devel- tant to recognize that experience as real, and not oping a working conceptualization based on the ‘all in your head.’…What automatic thoughts come client’s presentation and the theoretical basis of up for you when you think, ‘Here’s another co- AR and sharing that conceptualization with the worker who thinks I’m just the help because I’m a client in a way that is validating and that the cli- Black woman’ or ‘People will give him credit, and ent understands are important parts of AR. A not me, for winning the case?’” Here, the therapist strong therapeutic alliance in which the client would look for any signs that Kayla may think she trusts the therapist is also crucial, particularly is “less than” or unworthy of credit and normalize since the intervention requires buy-in from the the experience of having those thoughts while client, who is required to practice AR outside of using strategic questioning to evaluate them. the session (Hayes-Skelton, Roemer, Orsillo, & Borkovec, 2013). For clients whose anxiety is connected to or exacerbated by their experiences Applied Relaxation (AR) of marginalization or discrimination, a suggestion that is interpreted as “just relax” would feel Applied relaxation (AR) is an anxiety interven- especially invalidating and off-putting. Thus, it is tion aimed at working with clients to identify important to contextualize the recommendation their early indicators of anxiety and develop of AR and emphasize that AR will not reduce the 238 J. R. Graham-LoPresti et al. frequency of discrimination or make the pain of Worry Exposure (WE) such experiences go away, but it can help the client to deal with it more effectively. Worry exposure (WE) is an intervention that For example, the fictional client Syed is a requires clients to create and focus for 25 min 40-year-old Pakistani American Muslim man on a vivid mental image of their most feared diagnosed with GAD. He worries frequently, feels outcome or expectation from a situation they tense throughout most of the day, is irritable, has worry about. This exposure results in “habitua- difficulty remaining focused, and regularly experi- tion to the feared image and the accompanying ences headaches and stomachaches. Despite build- arousal, and changing the meaning of the ing up a modest amount of wealth and receiving feared situation” (van der Heiden & ten Broeke, several promotions at the job he has worked the 2009; p. 388). Consideration of the potential past 15 years, Syed worries about financial matters unintended outcomes that could arise because and job security. Syed experiences racial profiling of this habituation is important for culturally and targeting almost every time he goes to the air- responsive WE. For example, becoming habit- port, and travelling has become a hassle for him. uated to experiences of oppression may result He generally worries about his own safety and that in reduced anxiety, but it also may have the of his family, and he worries that they will experi- unintended consequence of reducing the emo- ence more difficulties because of the increasingly tions that push people to resist oppression. As anti-Muslim and anti-immigrant climate. Syed has part of the informed consent process, it is close friends who have been victimized by hate important for therapists to fully explain the crimes due to being perceived as immigrants or as intervention, particularly highlighting the like- Muslim and others who felt they were denied jobs lihood of experiencing emotional discomfort or housing for the same reasons. After hearing and the possibility of unintended consequences about Syed’s symptoms and experiences, his ther- like lessened drive for resistance. Culturally apist introduces AR saying, “I think learning how responsive therapists might consider how they to relax could help with your anxiety. Research could work with a client who values resistance suggests that for most people, anxiety is like a to engage in it without being motivated by feedback loop, with physiological responses lead- worry. Ideally, therapists also would take steps ing to negative thoughts, which intensify the phys- to reduce systemic inequities as part of their iological response. One of the ways to break the own work. cycle of anxiety is to intervene in the physiological In WE, clients are first asked to engage in response so that you learn not to react so strongly.” self-monitoring to determine the nature of their Although the therapist is not incorrect, and worrying, and they are taught to identify the this explanation aligns with Öst’s (1987) sug- worries that cannot be addressed by problem gestion for discussing AR, a more culturally solving, which will be the targets for WE. With responsive way to introduce AR to Syed would one of those worries in mind, the therapist begin with validation of his experiences of helps the client to hone in on the worst possible anti-Muslim and anti-immigrant discrimina- outcome of the situation. Clients are then asked tion. After validating Syed’s experiences, a to picture the worst possible outcome in as culturally responsive therapist might introduce much detail as possible, fully experiencing the AR by starting with an explanation that AR uncomfortable emotions that accompany the will not be able to get rid of the anti-Muslim, imagined outcome. In selecting the worries and anti-immigrant climate, but it may be helpful worst possible outcomes to focus on, culturally in reducing the intensity of the understandable responsive therapists should attend to the cred- anxiety he experiences. Such an explanation ibility of the worry and the worst possible out- appropriately contextualizes and situates the come, in the context of historical, social, and major issue outside of the client as opposed to cultural factors. Following the 25-min expo- internal to him. sure, cognitive restructuring is employed to 17 Culturally Responsive Assessment and Treatment of Generalized Anxiety Disorder 239 encourage the client to consider as many alter- Mindfulness and Acceptance-Based native outcomes as possible. Particularly in the Approaches case of a more credible worst possible outcome, culturally responsive therapists might An abundance of research supports mindfulness focus the postexposure work on helping clients and acceptance-based approaches as efficacious to realize the personal and social resources at and effective in the treatment of GAD (Chiesa & their disposal should they encounter their most Serretti, 2011; Hofmann, Sawyer, Witt, & Oh, feared outcome. Finally, the therapist works 2010; Piet & Hougaard, 2011; Roemer & Orsillo, with the client to determine how effective the 2002; Strauss, Cavanagh, Oliver, & Pettman, exposure was at eliciting emotion, reducing the 2014). However, there is a dearth of literature intensity of the emotion, and eliciting believ- exploring the integration of multicultural princi- able alternative outcomes (van der Heiden & ples and mindfulness and acceptance-based treat- ten Broeke, 2009). ments in the treatment of GAD. Fuchs et al. For example, the fictional client Rosa is an (2015) engaged in a phenomenological study 18-year-old Guatemalan woman who came to exploring the extent to which clients from tradi- the USA when she was 5 years old. She is a tionally marginalized backgrounds felt that their DACA recipient and has a mixed-status family. identities affected their experience of an Rosa has been diagnosed with GAD. She fre- acceptance-based behavioral therapy for GAD. quently worries and feels anxious and appre- Several themes arose from these clients including hensive more often than not. Rosa worries the importance of inviting conversation about about a number of situations including school, barriers to engaging in valued action, or the her family, making mistakes, and both the past things that are most important to the client, bal- and the future. In therapy, Rosa agrees to ancing the need to maintain treatment fidelity and receive WE treatment for her GAD. When dis- tailoring the treatment to the unique needs of cli- cussing the worries Rosa had written down, ents, and overall making client-centered adjust- she and her therapist identify hypothetical ments as the needs of the client shifts during worries, one of which is Rosa’s worry that her therapy. The results of this study highlight the mother, who is undocumented, will be ways in which the needs of clients from tradition- deported. Rosa identifies her worst possible ally marginalized backgrounds can vary and the outcome as not being able to see her mother flexibility of therapists when working with again. Her therapist has her focus the exposure diverse clients from mindfulness and acceptance- on that outcome, and afterwards, the therapist based approaches is of crucial importance. asks Rosa to think about the possible alternative outcomes. Rosa becomes angry, stating that “this isn’t just a thought exercise; this is Integration of Multiculturalism my life!” A culturally responsive approach to and Mindfulness and Acceptance- WE would involve the therapist asking ques- Based Approaches tions to better understand the circumstances surrounding Rosa’s worry and her worst pos- As stated above, there are several themes associ- sible outcome. The therapist might still choose ated with the development and maintenance of to use WE with this worry and outcome; how- GAD including intolerance of uncertainty, prob- ever, after the exposure, instead of asking Rosa lematic relationships with internal physiological to think about alternative outcomes, the thera- and emotional responses, and behavioral avoidance pist might ask questions related to how Rosa (Dugas & Koerner, 2005; Roemer & Orsillo, 2002). might handle the real possibility of her moth- Specifically, from a mindfulness and acceptance- er’s deportation and the real possibility of not based framework, the development of GAD stems being able to see her again. from the following model by Hays (2008): 240 J. R. Graham-LoPresti et al.

Problematic Relationship with Internal Experiences

Behavioral Experiential Avoidance Avoidance/Constriction

First, this model suggests that the development oline to a fire. Therapeutic goals, from this per- and maintenance of GAD is characterized by cli- spective, include using both formal and informal ents’ problematic relationship with their internal mindfulness practice to develop an expanded experiences. Specifically, individuals who are awareness towards our internal experiences (e.g., struggling with GAD, from this perspective, often emotions, physiological responses). An addi- have a restricted awareness or focus on future-ori- tional focus includes using emotional regulation ented threat, which is a barrier to taking in other skills to be able to gain awareness of, label, and aspects of their environment, which may include regulate our emotions. positive stimuli or contexts as well as safe spaces. From a multicultural perspective, several In addition, according to the model, individuals aspects of this model can be tailored to the unique suffering from GAD tend to be fearful of their experiences of individuals from traditionally mar- emotions and critically judgmental about the diffi- ginalized backgrounds. First, the literature pro- cult physiological and emotional anxious responses vides a significant amount of evidence that that come up for them in the context of GAD. Given individuals from traditionally marginalized back- that internal experiences are viewed as dangerous grounds experience discrimination based on these or threatening, people struggling with GAD are identities with frequency and across contexts often motivated to avoid these internal experiences. (e.g., work, school, social environments) Many problematic behaviors can serve as experien- (Donovan, Galban, Grace, Bennett, & Felicie, tial avoidance including alcohol use or overeating 2012; Ming-Foynes, Shipherd, & Harrington, (Hays, 2008). In fact, worry can serve an experien- 2013; Pieterse, Todd, Neville, & Carter, 2012). In tially avoidant function. Specifically, the function fact, the experience of discrimination and its of worry is often the avoidance of somatic symp- effects connect directly to the psychological toms as well as distraction from more emotional mechanisms (e.g., lack of perception of control, contexts or topics (Borkovec et al., 2004; Borkovec intolerance of uncertainty, behavioral avoidance/ & Roemer, 1995). constriction) that contribute to the development Paradoxically, having a critical and judgmen- and maintenance of mental health struggles, tal approach to one’s emotional experiences tends including GAD (Graham-LoPresti, Abdullah, to exacerbate those emotions, akin to adding gas- Calloway, & West, 2017). 17 Culturally Responsive Assessment and Treatment of Generalized Anxiety Disorder 241

An individual’s perception of control over Additionally, experiences of discrimination life contexts, safety, and environment is directly might contribute to GAD for people from margin- linked to stress and anxiety (Dugas & Koerner, alized backgrounds through avoidance of the 2005). People from traditionally marginalized things that are most meaningful in their lives. backgrounds are not responsible for the experi- Wilson and Murrell (2004) describe the ways that ences of discrimination they endure and, in fact, both avoidance of our emotions and avoidance of have very little, if any, control over whether or meaningful contexts contribute to the maintenance not the events occur. In this context, discrimina- of stress and anxiety. The things that matter to us, tory experiences can elicit an understandable our values, become limited when the focus is perception of lack of control of one’s environ- solely on attempts to avoid distressing emotions, ment (a key feature of GAD), therefore contrib- specifically worry in the context of GAD. Moreover, uting to the development and maintenance of negative life events (e.g., discrimination) can cre- GAD. Specifically, people from traditionally ate rigid and inflexible ways of responding to our marginalized backgrounds (e.g., immigrants, anxiety that limit our ability to engage in the things sexual minorities, people of color) work hard to that are meaningful to us. For instance, an indi- provide for themselves and their families, live in vidual who experiences worry about their safety accordance with their own values and societal and the safety of their loved ones based on experi- expectations, and expect to receive equitable ences of discrimination may begin to avoid places treatment, dignity, and respect in response to where they fear experiencing discrimination. For this hard work. Despite hard work, determina- instance, a transgender woman may begin to worry tion, and perseverance, the perception that one about her physical safety as she is inundated with cannot control their own safety, livelihood, and news of violence against people who identify as environmental contexts is initiated and main- transgender across the USA. This worry and fear tained by the frequency of discriminatory expe- might be a barrier to her engaging socially, attend- riences. This type of uncertainty can be directly ing her classes, and living up to her work obliga- connected to stress and worry that underpin tions. However, her avoidance of places where GAD. Therapists must develop an understand- they might experience discrimination is in direct ing of the ways in which frequent and pervasive contrast to their value of getting an education, experiences of discrimination can elicit signifi- developing a professional identity, and developing cant worries about emotional and physical close interpersonal relationships. As another safety. Most importantly, therapists should example, there has been a significant uptick in vio- express to clients who experience frequent dis- lence against people who identify as Muslim in the crimination that their worry is reasonable given US context. Given this uptick in violence targeting their history and the history of the US context. Muslims, it might make sense to avoid certain In addition, clients from traditionally marginal- places to maintain physical and emotional safety. ized backgrounds might develop worry patterns Therapists working with diverse clients need to be as a potentially maladaptive coping mechanism aware of these experiences of oppression and for the uncertainty of discrimination. Therapists avoid suggesting or pushing people from tradition- can assist clients in seeing the ways in which ally marginalized spaces to move towards behav- worry can be a barrier to the use of effective ioral engagement in a way that is physically or emotional coping strategies (e.g., emotion regu- emotionally damaging. Instead, therapists might lation, valued living, social support). Teaching assist diverse clients in clarifying their values in clients flexible ways to cope with their emo- different contexts (e.g., school, work, family, com- tional responses to discrimination can empower munity) and help clients decide on behavioral them with a sense of agency over their emo- engagement strategies that limit exposure to physi- tional safety and livelihood. In fact, this can be cally and emotionally damaging contexts and described to clients as an act of resistance increase engagement in personally meaningful against oppression. activities. 242 J. R. Graham-LoPresti et al.

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Aileen Torres, Sumithra Raghavan, and A. Keshani Perera

Trauma and its aftereffects have a texture. The experience conveys meanings that derive from per- cal research has only recently turned its atten- sonal histories; cultural heritages; and the social, tion to the role of cultural factors including political, and spiritual contexts in which the painful event happens. (Brown, 2008, p. 3) gender, race, ethnicity, and sexual orientation. Members of marginalized groups are particu- Decades of research on trauma and its accompa- larly impacted due to the weight of historical nying effects have refined our conceptions of oppression, maltreatment, and structural disem- trauma, posttraumatic stress disorder (PTSD), powerment (Gone, 2013). This collective trauma and related symptoms, and the current DSM-5 may be passed on intergenerationally, as in the recognizes trauma as the direct exposure, experi- case of the Native American and African- ence, or witnessing of a traumatic event. The American communities in the USA (Pole et al., symptoms of PTSD may range from intrusive 2008). Among minority groups with immigrant recollections of the event to flashbacks that cause histories, individuals often carry premigration a reexperiencing of the trauma. It is common for trauma and postmigration stressors, which exac- trauma survivors to experience disruptions in erbate posttraumatic symptoms when exposed to sleep and appetite, along with a general sense of additional traumatic events (Silove, 1999). being on guard and distressed when exposed to These symptoms are further impacted by accul- cues that resemble the initial trauma (APA, turation challenges, which may hinder the cop- 2013). Epidemiological data indicates that 6.8% ing process (Abouguendia & Noels, 2001; of adults meet criteria for a diagnosis of PTSD Oppedal, Røysamb, & Heyerdahl, 2005). As (APA, 2013), although it is likely that many more such, cultural differences are not mere demo- are suffering but not presenting for diagnosis or graphic variables, rather they contribute nuance treatment. and complexity to our understanding of trauma, While widespread prevalence studies indicate the manifestations of posttraumatic symptoms, that women and members of minority groups and the response to treatment. experience disproportionately high levels of Triandis (1972) described culture as a soci- trauma (Pole, Gone, & Kulkarni, 2008), empiri- ety’s “characteristic way of perceiving the social environment” (Triandis, 1972, p. viii 3). Per Triandis, culture is a multifaceted construct that includes values, beliefs, norms, tasks, attitudes, A. Torres (*) · S. Raghavan · A. K. Perera and roles. Cross-cultural scholars have consis- William Paterson University, Wayne, NJ, USA tently affirmed that culture is the lens through

© Springer Nature Switzerland AG 2020 247 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_18 248 A. Torres et al. which people view the world, and traumatolo- sleeping and loss of appetite, and presents to a gists have added that a social-ecological frame- local clinic for medical attention. The treating clinician tells her that she should tell her husband that work that considers an individual’s relationship she forbids future target practice outings, yet to multiple environmental systems is useful for Amina insists that she cannot “disrespect her hus- understanding the impact of trauma (Orozco, band’s authority”. The clinician also attempts to Chin, Restrepo, & Tamayo, 2001; Torres & reassure Amina that target practice is safe, and her son will learn a valuable skill. Amina nods meekly Maldonado, 2017). and accepts a prescription for sleeping pills. Bronfenbrenner’s (1979) ecological systems theory provides the ideal framework and allows The aforementioned case is rife with cultural us to incorporate the varying responses to trauma missteps on the part of the clinician, beginning across cultures, particularly in cultures where with a lack of awareness of the client’s trauma concepts of psychology and mental health may history, an unfamiliarity with cultural roles, and differ significantly from mainstream Western unexamined biases regarding acculturation. A ideals. Within this framework, trauma symptoms culturally competent system incorporates culture can also be better understood by examining at all levels and adapts services to meet the needs somatic symptoms and idioms of distress. of culturally diverse clients (Betancourt, Green, Trauma survivors from cultures where psycho- Carrillo, & Ananeh-Firempong, 2016). For logical symptoms are stigmatized may complain trauma clients in particular, understanding and of gastrointestinal difficulties, headaches, back rapport building are essential to recreating an pain, or general fatigue, rather than depression environment of safety (Raghavan, 2018). or anxiety symptoms (Chester & Holtan, 1992; Rapport begins during the assessment process, Smith & Keller, 2007). There is strong evidence when the clinician demonstrates openness and that somatic symptoms are related to the emo- curiosity towards the client’s subjective experi- tional distress underlying anxiety and depression ence. Concretely, this involves basic communica- (Lipowski, 1988; Ritsner, Ponizovsky, Kurs, tion, which may be impacted by language Lib, & Modai, 2000). Although these symptoms barriers. In translating a measure from one lan- may genuinely reflect physical problems, others guage to another, a literal word-for-word transla- are patterned ways of discussing illnesses using tion increases the risk of compromising construct words that denote physical rather than emotional validity. The generally accepted method of trans- concerns (Hinton & Lewis-Fernandez, 2010). lating measures involves both translation and Studies have also found that certain ethnic back translation conducted by two separate quali- groups experience more reexperiencing, numb- fied translators. Discrepancies between the trans- ing, and dissociative symptoms (Rhoadesr & lations are discussed and attempts are made to Sar, 2005). Working with trauma in diverse pop- resolve them (Geisinger, 1994; Weeks, Swerisson, ulations, therefore, requires an understanding of & Belfrage, 2007). Both the original and trans- cross-cultural factors in assessment, diagnosis, lated measures should then be field tested with and treatment, as well as specific knowledge monolingual individuals and resulting scores be about the client’s cultural background. compared and reviewed by a translation commit- Amina is a 23-year-old mother of two who came to tee (Flaherty et al., 1988; Geisinger, 1994; Weeks the United States after her family fled violence and et al., 2007). However, many measures are not war trauma in Syria. They have lived in Texas for adapted according to these recommendations due two years and Amina has just started feeling com- to the cost, limited availability of skilled inter- fortable in their new home. Recently, her son was invited to practice target shooting with a new preters for uncommon languages, and the length friend and neighboring family. Amina did not feel of the translation process (Weeks et al., 2007). comfortable, but her husband encouraged her to be Weeks et al. (2007) argued that investing in sound open to their new culture. Hearing the gunshots, translation at the outset is ultimately a cost- Amina began shaking and having stomach pain. For several weeks she reported extensive difficulty effective process, because it increases the likelihood that “equivalence of meaning is maxi- 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview 249 mized, while data contamination is minimized” significant hurdle for researchers given the scar- (p. 163). city of funding available for descriptive research Raghavan (2018) describes that when assess- (Mitrushina, Boone, Razani, & D’Elia, 2005). ment does not involve written measures, skilled Mitrushina et al. (2005) cautioned that using out- interpreters are an essential component of the dated or inaccurate normative data may be as det- process. Several studies have shown that clients rimental as using entirely inaccurate instruments who are unable to communicate adequately with and may lead to misdiagnosis or inaccurate their treatment providers report lower satisfac- treatment. tion with care (Baker, Hayes, & Puebla-Fortier, Despite these challenges, many common 1998) and are at greater risk for misdiagnosis measures used with this population such as the (Ku & Flores, 2005). Language can impact Center for Epidemiological Studies Depression symptom presentation; when clients are inter- Scale (CES-D; Radloff, 1977), the Trauma viewed in a language other than their own, infor- Symptom Inventory (TSI-2; Briere, 2011), and mation about the presence and nature of the Harvard Trauma Questionnaire (HTQ; psychiatric symptoms may be lost or misunder- Mollica et al., 1992) do have extensive norma- stood (Farooq & Fear, 2003). tive data on community, clinical, and culturally Interpreters are invaluable because they often diverse samples. These data display considerable bridge cultural traditions in trying to translate the variation across cultural groups, confirming the client’s experience in a qualitatively meaningful importance of culture-specific norms. Manly way (Farooq & Fear, 2003). Although translation (2005) cautioned that when using culture-spe- improves the treatment provider’s opportunity to cific normative data, one runs the risk of attribut- gather accurate clinical information, it may add ing observed differences solely to culture and another dimension of complexity to the assess- misinterpreting the meaning of results. Thus, the ment process. In working with trauma survivors assessing clinician needs to strike a balance from non-Western countries, interpreters are between cultural sensitivity and diagnostic exposed to highly distressing content, which may specificity. further impact the accuracy of translation This chapter offers an introduction to work- (Akinsulure-Smith, 2007). ing with trauma in diverse populations. As Despite the challenges inherent in using inter- Triandis described, culture is multifaceted and preters, at present no viable alternatives exist for multilayered, and a thorough exploration of many of the individuals seeking treatment. each aspect of culture is beyond the scope of Research suggests that using an interpreter is still this review. We instead focus on three large superior to not using one, which may have far minority groups in the USA, African- more serious consequences to patient assess- Americans, Latinx persons, and Asian- ment, diagnosis, and treatment (Baker et al., Americans, but many of the theoretical 1998; Ku & Flores, 2005). principles and techniques can be adapted to Lastly, when assessing trauma survivors from other groups or applied to other aspects of cul- other countries, it is essential to use normative ture. As Summerfield (2005) cautions, the prob- data that is specific to the culture of interest. lem … is not one of translation between Establishing adequate criterion validity (Canino languages but of translation between worlds & Bravo, 1994) involves generating normative (p. 76). Therefore, in this chapter, we approach data for each culture and assessing whether a dis- different areas of traumatology in the context of order, symptom, or psychiatric phenomenon culture, to attempt to translate the representa- exists according to those norms. Normative data tion of trauma from one world to the other. not only needs to be collected at the outset, but The following section examines the treatment also periodically updated, which often presents a of trauma in Asian populations. We describe the 250 A. Torres et al.

Asian diaspora in the USA and discuss the impact itself, informed by its colonial past and individ- of culture on symptoms and treatment. ual national struggles. The perceived success of the US Asian population may mask its struggles to the population at The Asian Diaspora in the USA large. Indeed, data indicates that US residents have less familiarity with Asian culture as com- Tenzin is a refugee from Tibet who has been in the pared to African-American and Latinx culture, US for 2 years. Chinese police raided her home in are more likely to endorse stereotypes, and pre- Tibet and found books and photos from His Holiness The Dalai Lama. Tenzin and her family sume wider cultural distance between groups were beaten, imprisoned in solitary confinement, (Gee, Ro, Sherriff-Marco, & Chay, 2009). The deprived of light and sanitation, and then released. damaging impact of the “model minority” myth The Chinese police returned and found parapher- is well documented (Gupta, Szymanski, & nalia on one other occasion and Tenzin was imprisoned and starved for three days before her release. Leong, 2011; Qin, Way, & Mukherjee, 2008), She has applied for asylum, and one week prior to and Asian-Americans who internalize positive her interview, she visits a clinic reporting indiges- stereotypes but fail to enact them are more likely tion, diarrhea, and cramps. The nurse interviewing to experience symptoms of depression, anxiety, her is alarmed by her trauma history and assessed for PTSD and depression. Tenzin denies all mental low self-esteem, and suicidal ideation. This health symptoms, saying she’s generally doing reflects what Chan and Mendoza-Denton (2008) well, does not think about her past or her feelings termed “status-based rejection sensitivity” and in general. “I am a grain of sand in a larger world,” has the particularly insidious effect of reducing she states, and maintains that she wants to make sure her she is physically healthy for her asylum the likelihood of help-seeking, thus prolonging interview. distress symptoms (Inman & Yeh, 2007). Data on mental health service use in Asian-Americans The US Asian population is diverse, with over 20 reveals significant disparities: Among those with million Asian-Americans tracing their roots to a diagnosable mental health condition, only 28% more than 20 countries in East and Southeast used services, as compared to 54% of the general Asia (Pew Research Center, 2017). The largest population (Le Meyer, Zane, Cho, & Takeuchi, segments of the Asian population in the USA 2009). When Asian-Americans do engage in draw from China, India, and the Philippines. treatment, many withdraw within fewer than five Data from the Pew Research Center (2017) indi- sessions (Le Meyer et al., 2009). While research cates that they are projected to become the largest does reveal a mediating effect for acculturation immigrant group in the USA, surpassing Hispanic status, rates are still significantly lower than those immigrants by the year 2055. of White Americans. Sociodemographic data from the Pew Research Center (2017) suggests that US Asians do well in comparison to the general US popula- Trauma Exposure in the Asian tion, with higher levels of education and higher Population median incomes. However, these findings vary significantly by subgroup. For example, immi- Data on trauma exposure in the US Asian popula- grants from India have the highest median tion is inconsistent, with some studies suggesting incomes (approximately $100,000), while immi- that Asians experience lower rates of trauma and grants from Burma have the lowest, with median PTSD (Alegría et al., 2013) and others indicating incomes of $36,000. Additionally, US Asians rates to be equivalent to that of other minority earn significantly less than White counterparts groups (Sue, Cheng, Saad, & Chu, 2012). The with comparable education levels (Park & Kim, specific types of trauma experienced by US 2008) and, despite overall economic success, are Asians vary and reflect the geography, culture, also less likely to own homes. This wide range and sociopolitical climate of their countries of reflects the complexity and diversity of Asia origin. 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview 251

Researchers have described Southeast Asian sure or engagement in treatment. However, Gim, refugees as a particularly high-risk group with Atkinson, and Whitely (1990) found that Asian- regards to trauma and PTSD (Sue et al., 2012). American women expressed interest in partici- As an example, Marshall, Schell, Elliot, Berthold, pating in treatment, which suggests that early and Chun (2005) examined the mental health of outreach may help. Cambodian refugees and found that over 90% of To effectively provide care and treatment for respondents experienced near-death from starva- minority populations, clinicians must recognize tion, forced labor, and having a family member or the cultural variables that may influence the man- friend murdered as a result of political violence. ifestation of symptoms (Chester & Holtan, 1992). Not surprisingly, 64% of these respondents met Culture can exert a powerful and often misunder- criteria for PTSD. In fact, Asians overall report stood influence on psychological assessment, and higher rates of exposure to war trauma in com- the challenge is to account for the social ecology parison with other groups (Roberts, Gilman, and subjective experience of the client, as well as Breslau, Breslau, & Koenen, 2011) along with the objective symptoms or behaviors present migration trauma and postmigration stressors (Ridley, Tracy, Pruitt-Stephens, Wimsatt, & including linguistic difficulties, poverty, under- Beard, 2008). The following section will detail employment, and exposure to bigotry and preju- the ways in which culture can impact the assess- dice (Roberts et. al., 2011). ment and manifestation of symptoms in Asians. Similar results were found in studies of Asian immigrants who were victims of natural disasters (see Bryant, 2006; Udomratn, 2009). The Asia- Impact of Culture on Trauma Pacific region has suffered the highest number of Symptoms in the Asian Diaspora natural disasters in the past 20 years including cyclones, earthquakes, and floods causing death, As described in earlier sections of this review, injury, and property destruction. Victims of natu- culture can have a powerful impact on mental ral disasters may become permanently displaced health and the manifestation of symptoms. Many as entire settlements are destroyed and may emi- trauma survivors may report somatic symptoms grate to countries such as the USA to begin anew. in lieu of psychological ones and may evidence Beyond mass trauma and immigration stress- entire culture-bound syndromes. One clear chal- ors, US Asians also suffer interpersonal trauma, lenge reflected in the above data relates to under- although there is a lack of systematic research on reporting and inconsistent reporting of trauma the topic (Sue et al., 2012). Ho’s (2008) examina- exposure and symptoms. This can be explained in tion of violence in Asian-American communities two ways: first, stigma around mental health and suggested that a staggering 77% of Asian and cultural values around shame, saving face, and Pacific Islander adolescents had been exposed to protecting family integrity can be impediments to physical or community violence in their lifetime, reporting. The impact of stigma on use of clinical with over 40% reporting direct victimization. services in Asian communities is well docu- This finding is consistent with other research mented, with Asians reporting the lowest levels reporting high rates of physical abuse in Asian of service use, even among those who meet crite- communities (Ima & Hohm, 1991; Kenny & ria for a diagnosable psychiatric condition (Abe- McCeacham, 2000). Kim et al., 2007). These patterns persist even A particularly vulnerable subpopulation among US-born Asians and only equalizes in the includes Asian women, who do report elevated third generation of immigration, wherein clinical rates of trauma exposure and mental health service use patterns are more on par with those of symptoms than Asian men (Sue et al., 2012). White Americans. Alternatively, as previously Cultural values surrounding the inferior status alluded to, cultural conceptualizations of mental of women and the expectation of deference to health in Asians may differ widely from those of male family members create barriers to disclo- mainstream Western culture, and as such, Asians 252 A. Torres et al. may not perceive themselves as experiencing equivalent of major depression and involves psychological distress in similar ways. physical symptoms including muscle weak- Many somatic symptoms may also be consid- ness, shortness of breath, sweating, and fainting ered idioms of distress. Specific to Asian trauma (Kleinman, 1997). Similarly, the Korean syn- survivors, for example, is the “weak heart” syndrome “Hwa-byung” was observed initially by drome present among Cambodian refugees who Lin (1983) and described in the Diagnostic and survived the Pol Pot dictatorship. Hinton et al. Statistical Manual of Mental Disorders, fourth (2002) described the symptoms of weak heart as Edition (American Psychiatric Association including intense fear, physical exhaustion, heart [APA], 1994). This term literally translates to palpitations, and an exaggerated startle response, “fire illness” and, examined as such, may be suggesting that it may fit within the nosology of difficult to understand. In context, it refers not anxiety disorders. Sufferers perceive the heart as only to the gastric distress of what Western failing in its role, therefore becoming “weak,” and societies may refer to as “heart burn,” but addi- conveying both physical and psychological dis- tionally to a metaphorical “burning with anger.” tress (Hinton, Hinton, Um, Chea, & Sak, 2002). Thus, it refers to both physical and emotional There are also a number of culture-bound syn- distress associated with the experience of dromes present in Asian cultures that may be evi- intense anger (Kirmayer, 2001; Lin, 1983). dent in Asian trauma survivors in the Understanding the value placed on emotional USA. Culture-bound syndromes are thought to suppression may aid clinicians in “reading be patterns of symptoms specific to an individu- between the lines,” so to speak, and understand- al’s culture, although research suggests that there ing that Asian clients may be describing intense is often overlap across cultures. Listing and psychological distress in physical terms. describing every Asian culture-bound syndrome Asian culture also places value on spiritual present is beyond the scope of this review, but and ancestral connections, and culture-bound Yeh, Ngyuen, and Lizzaraga (2014) indicate that syndromes may reflect this phenomenon. For they typically fall into categories that reflect example, in Taiwanese culture, hsieh-ping Asian cultural values. Understanding these value involves periods of disorientation where one is systems is essential to working with this client exposed to ancestral ghosts who are attempting to population. connect with them (Yeh et al., 2014). Trauma sur- Many Asian cultures present some variation of vivors experiencing bereavement or loss may the dhat syndrome, which reflects the value of the communicate in these terms and should not be mind-body connection. The dhat syndrome origi- misdiagnosed as having psychotic symptoms. nates in India and refers to intense anxiety and A final theme Yeh et al. (2014) discuss is that hypochondriacal beliefs around the discharge of of interdependence and a collectivist orientation, semen in males (American Psychiatric Association, which may appear to stand in direct contrast to 2000). A similar variation is found in Chinese cul- the independence and individualism emphasized ture, where semen is considered to hold chi, or by Western culture. This may be reflected in the energy, for men, and its loss can be anxiety pro- phenomenon of hikikomori in Japan, whereby voking (Yeh et al., 2014). Understanding of the adolescents and young adults unexpectedly with- mind-body connection and specifically concerns draw from society and isolate themselves for a around this topic may be helpful in assessing minimum of 6 months. This is believed to be a Asian survivors of sexual trauma. result of fear of disappointing parents and an Culture-bound syndromes often include inability to meet social and academic pressures. somatic symptoms, as described earlier, and The existence of a syndrome whereby young reflect both the mind-body connection and the people are in deep despair due to disappointing Asian value of emotional suppression. their parents represents the power of the interde- Neurasthenia is often considered the Chinese pendent cultural value, and a culturally sensitive 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview 253 clinician should be aware of these value differ- engaging in mental health counseling (Leong & ences and mindful of pathologizing them. Lau, 2001). For those who do enter treatment, there is limited empirical research regarding psychotherapy Treatment of Trauma efficacy for Asian-American clients. Sue, Zane, and Guidelines for Culturally and Young (1994) found that studies focused Informed Care more on preferences of clients than actual psychotherapy processes and outcomes. Sue et al. This final section will discuss the treatment of did find that ethnicity matching increased reten- trauma in Asians and provide some guidelines for tion in treatment for Asian-American clients but culturally informed care. Researchers have cautions that more research is needed on cultur- argued that collectivistic values that are traditionally appropriate services. ally held by Asian-Americans (Triandis, 1988) Recent research on Bangladeshi immigrants oppose the values associated with Western psy- offers promising results using a community-based chotherapy (Leong, Wagner, & Tata, 1995). model. Karasz et al. (2015) worked with members Many traditional psychotherapy orientations of the immigrant community to develop a cultur- place high value on open verbal communication, ally consistent treatment for an indigenous syn- exploration of intrapsychic conflicts, discussion drome “tension,” similar to major depression. The of family and childhood difficulties, and a focus researchers rejected the notion that Asian immi- on the individual. Sue (1977) maintains that these grants lack mental health literacy as embedded in processes encourage the client to put their own Western notions of psychology and inherently individual goals before those of the collective, placing blame on the clients themselves. In con- which is in direct conflict with traditional Asian stant, they proposed that treatments developed views. within the value framework of that culture were Furthermore, Western psychotherapy’s empha- more likely to be effective. Using a community- sis on open communication regarding family based participatory model, the researchers devel- experiences and overt displays of emotion also oped a group-based treatment focusing on feel culturally inconsistent. Leong and Lau (2001) concrete goals including building financial liter- indicate that for many Asians, the sphere of inti- acy and assertiveness skills and facilitating social macy extends to immediate family and perhaps connections. Preliminary trials of this treatment extended family, but rarely further. Members of suggest it was effective in reducing psychological societies with these values often see disclosure of symptoms and participant attrition rates were sig- personal and family problems as bringing shame nificantly lower than what is typically reported in upon one’s family, which is viewed as a serious studies with minority clients. The authors describe offense. In fact, research by Tabora and Flaskerud the strength of the intervention as being culturally (1997) found that the cultural value of avoiding synchronous with client’s value systems, thus family shame often outweighs the stigma of allowing it to be more effective. This approach help-seeking. provides a model for developing culturally con- For trauma victims, these values also create sistent interventions in the future. the additional barrier to disclosure and may in The treatment of trauma in Asian populations part explain the low reported prevalence rates of then depends on a willingness to operate within trauma in Asian populations. In particular fear of their framework. In many ways this is consistent shame and desire to save face may impact indi- with modern Western views of psychotherapy, vidual’s willingness to disclose interpersonal where therapists are encouraged to enter into the trauma such as physical or sexual abuse. These client’s subjective experience and understand value systems persist even among highly accul- their worldview. Because trauma assaults an indi- turated Asians, who still report a low interest in vidual’s sense of safety in the world, and inter- 254 A. Torres et al. personal trauma in particular violates the est event was the day that she received a call from survivor’s sense of personal integrity and com- prison. They told her that she had to kill the person whom she most loved in order to become a part of fort with others, culturally informed clinicians the gang. She stated that the unspoken but clear have the opportunity to provide a meaningful implication was that she must join the gang by kill- corrective emotional experience to clients and ing her mother and if she didn’t, then her whole truly facilitate healing. family would die. She fled to the United States because she wanted to ensure the safety of her fam- Leong and Lau (2001) summarize the impor- ily and to escape this threat. While crossing the tance of several treatment modifications for border, she considered drowning herself in the Asian-American clients, including the clinician river in the hopes that this sacrifice would save her other family members. She spent two months in an establishing credibility with the client (Kinzie, immigration detention center. She described being 1985; Zane & Sue, 1991), enlisting family sup- worried because chunks of her hair were falling out port in treatment (e.g., Sue & Morishima, 1982), because of her “nervios.” proceeding slowly affective experience (e.g., Lorenzo & Adler, 1984; Nishio & Blimes, 1978), Hispanic Americans are estimated to comprise incorporating the client’s interpretation and 17.8% of the total US population, making up the meaning of his or her symptoms into the assess- largest ethnic minority group in the USA ment and treatment process (Tanaka-Matsumi, (U.S. Census Bureau, 2016). Latino/as constitute Sieden, & Lam, 1996), and using directive, con- a diverse population with distinct ethnic and crete, problem-focused techniques (Kim, 1985). racial compositions (Indigenous, Black, and These recommendations share in common a White), as well as unique histories of migration respect for indigenous values that portray the cli- to the USA. Hispanics originate from more than nician as a medical professional, the family as 20 countries in North, Central, and South paramount sources of support, and the expression America, as well as the Caribbean. Each country of emotion as uncomfortable and difficult. Leong and its subregions have their own unique dialect and Lau (2001) further caution against using non- and customs. Approximately 64% of those of directive, abstract psychodynamic techniques Hispanic/Latino origin in the USA were of that may alienate or confuse the client. Overall, Mexican origin. Another 9.5% were Puerto clinicians should approach culture with curiosity Rican, 3.7% Cuban, 3.8% Salvadoran, and 3.2% and consider interventions that connect with Dominican (U.S. Census Bureau, 2016). Among those values. This approach is most likely to the 3.4 million Central Americans residing in the build rapport and facilitate healing in vulnerable USA, it is estimated that 85% percent hail from populations. El Salvador, Guatemala, and Honduras (Lesser & The following section will explore the cultural Batalova, 2017). dynamics unique to the Hispanic/Latinx dias- The proper use of the terms Hispanic, Latino/a, pora, as well as trauma symptoms and exposure and Latinx has been frequently contested. rates in this population. Hispanic is the “politically conservative term,” while Latino is the “progressive/politically correct term” (Garcia-Preto, 2005). Technically, Hispanic/Latinx Diaspora in the USA Hispanic refers to Spanish-speaking countries in the “New World” which were colonies of Spain, Maria, a 19-year-old from El Salvador, disclosed whereas Latino (masculine term) is more fre- that she had witnessed an uncle’s bullet ridden quently used to refer generally to anyone of Latin- dead body on the floor following his murder. Maria remembers hearing gunshots at night on a weekly American origin or ancestry, including Brazilians. basis and eventually gang members threatening to Latina is the feminine form of the word and the kill her brother. As she raised her shirt displaying a gender-neutral term Latinx has been used more keloid scar, she reported that at 12 years old a gang recently. Clients should be allowed to self-iden- member threw boiling water at her abdomen severely burning her. She described that the scari- tify and provide their own view of the verbiage. 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview 255

According to the Pew Hispanic Center’s National the need for socialization that is pleasant and Survey of Latinos (Taylor et al., 2012), more than lacking confrontation or negative interactions; half (52%) of Latinos ages 16–25 identify them- similarly, personalismo is having trust and warm selves first by their family’s country of origin. interpersonal interactions with others. Finally, Approximately, 20% generally use the terms fatalismo is a belief that illness and misfortune “Hispanic” or “Latino” first when describing are beyond a person’s control and are attributed themselves. Only about one in four (24%) gener- to fate and one could potentially feel a sense of ally use the term “American” first. This chapter resignation (Caplan et al., 2011). In the spirit of will not debate the validity or technicality of these Triandis’s definition of culture, these values are terms and will use them interchangeably. likely to impact Latinx persons’ interpretations However, it should be noted that the population and reactions to trauma. that is being referred to below, regardless of the Latinx immigrant groups have a high proba- term used, focuses solely on the people from the bility of trauma exposure prior to their immi- Latin-American and Caribbean Spanish-speaking gration to the USA (Jha, Orav, & Epstein, 2011; countries that had been colonies of Spain in the Perreira & Ornelas, 2013). Central America’s past and do not include Spain, other European Northern Triangle (El Salvador, Guatemala, and countries, or Brazil. Honduras) is one of the world’s most violent In addition to being the largest ethnic minority regions due to a combination of political insta- group, the Latinx population in the USA are also bility and corruption, as well as significant gang among the youngest ethnic minority groups. violence (Prado-Perez, 2018). There has been While levels of education are increasing, only instability and violence in Mexico and about 15% of Hispanics earn a bachelor’s degree Venezuela; Venezuela has experienced drastic or higher, which is much lower than the rates of economic decline in the past 10 years (Ellis, Asians (63%), Whites (41%), and Blacks (22%) 2017) Venezuela has been experiencing a politi- (Stepler, 2016). It is noteworthy that US-born cal and economic crisis which has caused it to Latinx youth go farther in school than their immi- go from being among the richest to the being grant parents, who represent a declining subset of the poorest (Fisher & Taub, 2017). Mexico is the Latinx population overall (NASEM, 2015). one of the countries experiencing violence The disparity in educational outcomes has a sig- related to drug trafficking. Additionally, Latin- nificant impact on the Latinx community, who American countries have suffered numerous disproportionately occupy the lower rungs of the natural disasters. In 2017, hundreds of deaths socioeconomic ladder. resulted from Mexico’s two earthquakes (mag- nitudes between 7 and 8), flooding in Peru, and landslides in Colombia (Umbert, 2018). Even in Trauma Exposure in the Latinx the USA, 1 year later, Puerto Rico is still recov- Diaspora ering from the aftereffects of the Category 4 Hurricane Maria which is thought to have killed While there are many differences between 2975 people (GWU, 2018). groups, there are some cultural values endorsed Latinx immigrants often emigrate in stages, by most Latinx groups to varying degrees. For resulting in separation from family and primary example, familismo refers to maintaining a close caregivers (NCTSN, 2007; Santa-Maria-Cornille, connection to the family, relying on the family to 2007). In addition to premigration trauma, new meet psychological, social, and security needs arrivals often contend with a fear of deportation (Interian & Diaz-Martinez, 2007). It also refers and worry for family left at home (Eisenman, to the willingness to make personal sacrifices for Gelberg, Liu, & Shapiro, 2003; Silove, Momartin, the welfare of the family and a shared sense of Marnane, Steel, & Manicavasagar, 2010; Steel responsibility (DeArellano, 2006). Simpatia is et al., 2009). 256 A. Torres et al.

The APA Presidential Task Force on variation in prevalence rates, research does sug- Immigration (2012) indicates that immigrant gest that Latina/os exhibit an increased risk of youth may experience potentially unique trau- PTSD symptoms after exposure to a traumatic matic experiences. These experiences include event (Eisenman et al., 2003). This holds true racial profiling, ongoing discrimination, expo- even when adjusting for differential exposure and sure to gangs, immigration raids, the arbitrary sociodemographic factors. Latinx individuals are checking of family members’ documentation sta- more likely than non-Latinx White counterparts tus, forcible removal or separation from their to exhibit more chronic and severe PTSD symp- families, placement in detention camps or in tom trajectories (Hinton & Good, 2015). An child welfare, and deportation. Latino/a immi- established body of research indicates that grant adults could be at a higher risk of work- Hispanic adults are more likely than their non- related discrimination and exposure to domestic Hispanic counterparts to experience severe symp- violence (APA Task Force on Immigration, toms of posttraumatic stress disorder (PTSD); 2012). however, explanations for this phenomenon vary While a sizeable portion of Latinx persons (Escobar et al., 1983; Galea et al., 2004; Kulka experience immigration-related trauma, research et al., 1990; Lewis-Fernandez et al., 2008; Norris often fails to address the important differences et al., 2001; Pole et al., 2001; Schell & Marshall, between US-born Latinos/as and recent immi- 2008). Some of these explanations for this phe- grants. In fact, the majority of Hispanics are US nomenon include a culturally based propensity to born and experience unique challenges as minor- exaggerate or overreport mental health symptoms ities in their nation of birth. Indeed, perceptions (Ortega & Rosenheck, 2000; Ruef, Litz, & of discrimination are more widespread among Schlenger, 2000), a disposition toward acquies- US-born (62%) than foreign-born (41%) young cent responding (Ortega & Rosenheck, 2000), Latinos (Pew Research Center, 2016). As previ- and the tendency of Latinx to manifest suffering ously mentioned, US-born Latino/as are more in physical rather than psychological form likely to have proficiency in English and com- (Hough, Canino, Abueg, & Gusman, 1996). plete high school, and as such the nature of their Other explanations include differences in the trauma exposure is likely different than that of experience of traumatic life events (Frueh, Brady, the parent generation. However, clear data is & de Arellano, 1998), increased ethnic discrimi- unavailable as much of the ethnicity-based nation (Loo et al., 2001; Marsella, Friedman, & research on trauma in specific groups (e.g., police Spain, 1996), lack of coping resources following officers, veterans) likely included a predomi- trauma exposure (Pole, Best, Metzler, & Marmar, nately US-born sample or did not differentiate 2005), as well as sociodemographic disadvantage between the US-born or immigrant groups (Pole et al., 2008). (Escobar et al., 1983; Galea et al., 2004; Kulka In their study of traumatized veterans, Hall- et al., 1990; Lewis-Fernandez et al., 2008; Norris, Clark et al. found that both Hispanic and African- Perilla, & Murphy, 2001; Pole et al., 2001; Schell American service men reported more symptoms & Marshall, 2008). such as reexperiencing, fear, guilt, and numbing than their White counterparts. There is an indica- tion that peritraumatic responses (reactions Trauma Symptoms in the Latinx immediately following the event), such as peri- Diaspora traumatic dissociation or peritraumatic panic attacks, are associated with higher levels of Epidemiological research of PTSD in the Latinx PTSD. Hispanics have been found to endorse population reveals a wide range from 4% to 38% more peritraumatic dissociation such as deper- (Alegría et al., 2008; Cervantes et al., 1989; sonalization and derealization, as well as panic Eisenman et al., 2003; Santa-Maria & Cornille, attacks, than other groups (Alcántara & Lewis- 2007; Steel et. al., 2009; Yule, 2001). Despite Fernandez, 2016). Peritraumatic dissociation was 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview 257 also associated with PTSD severity in Latino/as prevalence of ataques has been found to be asso- exposed to community violence (Denson et al., ciated with a prevalence of various disorders and 2007). Alcántara and Lewis-Fernandez (2016) symptoms, including PTSD, dissociative symp- suggest that peritraumatic responses account for toms, and panic disorder (Alcántara & Lewis- a large percentage of variance in the risk of Fernandez, 2016; Guarnaccia et al., 1996; Latino/as and non-Hispanic Whites. However, Lewis-Fernández et al., 2010; Schechter et al., depersonalization and derealization are not com- 2000). It has been postulated that once exposed to monly assessed symptoms. These symptoms a traumatic event, a peritraumatic reaction in the include feeling detached from their own feelings form of an ataque de nervios may increase the and/or experiences (depersonalization) and/or odds of PTSD onset or its prognosis (Alcántara & experiencing objects, people, and/or surround- Lewis-Fernandez, 2016). ings as unreal, distant, artificial, and lifeless Similarly, to simply suffer from “nerves” can (derealization) while maintaining intact reality imply chronic anxiety, somatization, depression, testing abilities (Michal et al., 2016). These dif- and/or dissociation (Hinton & Lewis-Fernandez, ferent manifestations of distress may require dif- 2010). The term nervios includes a wide range of ferent treatments. symptoms of emotional distress, somatic distur- Working with trauma in Latinx populations bance, and inability to function. Nervios is requires a knowledge of idioms and distress and described as episodes, usually chronic, of extreme culture-bound syndromes, many of which incor- sadness or anxiety associated with somatic symp- porate supernatural explanations for their distress toms such as headaches and/or muscle pain, nau- or unusual physical presentations (Caplan et al., sea, loss of appetite, fatigue, insomnia, and 2011). This may include belief in concepts such decreased reactivity. It is more common in as “mal de ojo” (evil eye) and witchcraft or hexes. women and associated with stress, emotional One of the most empirically established culture- imbalance, and low self-esteem (Nogueira et al., bound syndromes is ataque de nervios or “attack 2015). Ecuadorian Andes children also experi- of nerves” and is a common idiom within ence the “nervios” disorder with varied symp- Caribbean-Latino/a populations (Hinton & toms such as increased sadness and anger. This Lewis-Fernández, 2010). For some, ataque de disorder is often said to be triggered by the chil- nervios are considered as a normal reaction to a dren’s separation from their parents, especially stressful or traumatic event which is associated their fathers (Pribilsky, 2001). Mexican rural with losing control. Commonly reported ele- communities showed a prevalence of 15.5% in ments of ataques include screaming and shouting the general population for the diagnosis of uncontrollably, attacks of crying, trembling, heat nervios (Rhoades & Sar, 2005). in the chest rising into the head, and becoming Susto, which literally translates to “fright,” is verbally and physically aggressive. Dissociative more commonly found in Mexico, Central experiences, seizure-like or fainting episodes, America, and South America. Symptoms include and suicidal gestures are prominent in some feelings of sadness, apathy, and low self-esteem ataques but absent in others. The attacks are along with somatic symptoms including sleep often triggered by stressful events relating to the and appetite disturbances along with gastrointes- family, such as news of the death of a close rela- tinal distress. Those suffering from “susto” tive, conflicts with a spouse or children, or wit- believe that the experience of a frightening event nessing an accident involving a family member. can cause the soul to leave the body. As such the Ataque de nervios is most commonly found “soul-less” person is left with sadness and sick- among Hispanic older females (Guarnaccia et al., ness. Traditional healing will focus on calling the 2010) even though the original research on soul back to the body and cleansing the person. ataque de nervios was conducted by US military The “cleansing” is intended to restore the body psychiatrists in the 1950s and 1960s addressing and spiritual balance (American Psychiatric symptoms in Puerto Rican military males. The Association, 2013). Often the practice of curand- 258 A. Torres et al. erismo, a form of Hispanic traditional folk be involved in the required documentation needed medicine, is used. This practice focuses on using for these varying claims (i.e., asylum, VAWA, U natural plants to spiritually heal and obtain bal- visa, T visa). Abused spouses of US citizens and ance (Tafur, Crowe, & Torres, 2009). legal permanent residents (LPR) or the non- abused spouse whose child was abused may be eligible for VAWA. Victims of certain crimes Treatment Guidelines for Working (including rape, incest, domestic violence, abu- with the Hispanic/Latinx Clients sive sexual contact, abduction, felonious assault) who cooperate with police investigations may be Experts recommend that treatment with Latinx eligible for a U visa. Victims of human traffick- immigrant clients emphasize the importance of ing who have reported this crime to officials and thoroughly exploring the client’s context of exit are cooperative with the investigation are eligible from the country of origin and current neighbor- for a T visa. A person who is unable or unwilling hood circumstance in the overall assessment of to return to home country due to persecution on the client’s well-being (Alegría & Woo, 2009). account of race, religion, nationality, political Clients may be reluctant to disclose their immi- opinion, or membership in a particular social gration status and/or their premigration traumatic group could be eligible for asylum (Torres & experiences. For example, one research study had Mercedes, 2018). found that only 3% of the 267 Latinx patients Beyond understanding immigration and accul- who had experienced political violence reported turation experiences, clinicians should pay close ever telling a clinician about it after immigrating attention to the nuances of symptom presenta- (Eisenman, Gelberg, & Shapiro, 2003). tion. For example, clinicians should inquire about Traumatized patients may be silenced by shame, somatic symptoms, dissociation, and peritrau- guilt, and mistrust and may not see their past matic responses that standard clinical interviews trauma as related to their current complaints may not address. Additionally, a culturally (Keller, Leviss, Levy, & Dyson, 2007). In addi- informed evaluation should also directly explore tion to exploring premigration stressors, postmi- issues related to ethnic identity and experiences gration experiences should also be assessed, as of discrimination. Formal measures such as the they may impact acculturation and adjustment. Hispanic Stress Inventory (HIS-2; Cervantes For example, Cuban immigrants who are able to et al., 2015) may be effective in the assessment access strong social, economic, and political net- process. works within ethnic enclaves fare differently than Pole, Gone, and Kulkarni (2008) identified immigrants from El Salvador who may lack relevant cultural factors such as language, social capital in the USA. In sum, clients may familismo, and personalismo in the treatment of present with different levels of acculturative Latinx persons. They emphasize that even when stress which may exacerbate posttraumatic Latinx clients speak English fluently, those who responses. Moreover, there may be significant spoke Spanish as their first language may recall differences even within families between immi- more details and access deeper emotions grant and US-born clients. (Altarriba, 2016) when they communicate in Undocumented clients may not be aware that Spanish. Clinicians should also assess the some of their premigration trauma and abuse- extent to which familismo is important to their related experiences may make them eligible for client, as treatment goals that incorporate the documentation. This process while stressful in family may be more culturally salient. For and of itself may lead to a reduction in stressors Latinos who endorse personalismo there will and increased opportunities in the future. be a preference for therapy relationships char- Therefore, clinicians could play a role in refer- acterized by greater emotional warmth. Latino/a ring clients to immigrant rights groups that could clients have frequently reported “coldness” help with the legal process. Clinicians could also among practitioners as a barrier to treatment 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview 259

(Guarnaccia, Martinez & Acosta, 2005; eign-born Black population, whereas approxi- Paniagua, 1994). mately half of all foreign-born Blacks living in the Clinicians working with this population USA (49%) were from the Caribbean, especially should respect culturally consistent ideas around Jamaica and Haiti (U.S. Census Bureau, 2016). healing. If a client views their trauma experience Africans in Africa are connected to African- as a part of fate and then using that language and Americans in the USA and other areas of the belief, therapists can reframe their goals. For larger Black diaspora, including the Caribbean, example, one can ask if the client believes that “through a common racial ancestry as well as fate or God could have brought them to the ther- through myriad political and historical circum- apy office to help them. If the client believes that stances” such as the effects of colorism (Alex- there is a hex, one could explore how the indi- Assensoh, 2009, p. 90). The Council of National vidual came to that conclusion and how they Psychological Associations for the Advancement believe they can be freed from this. In sum, the of Ethnic Minority Interests published by the client’s cultural myth about their illness requires Association of Black Psychologists (2003) indi- attention in order to strengthen treatment adher- cated that “acknowledging people of African ence and therapeutic alliance (Benish, Quintana, descent in this country, the focus of differences is & Wampold, 2011). often placed on race rather than culture.” The terms African or African immigrant refer to Black Africans, who have voluntarily migrated African/Black Diaspora from Sub-Saharan or Black African countries over the last two decades (Alex-Assensoh, 2009). The next section will provide an overview of the The African-American terminology refers to the African/Black diaspora, culturally specific differ- racial group in America, which traces its ancestry ences in exposure and symptomatology, and to African slave population beginning in the treatment recommendations. 1600s (Franklin & Moss, 2010). The term Black Sasha, an older African-American mother, from a refers to all individuals in America—including poor urban area was often dismissive of her young native-born African-Americans, African immi- baby boy with whom she was being reunified. grants, and other Black immigrants—who are There was no history of abuse towards this child ascribed as “Black” based on the American sys- but she had been “in the system” because Sasha had given up custody of her oldest child due to past tem of racial categorization (Alex-Assensoh, drug use. Sasha emphasized the need to be a strong 2009). However, there are many, very clear dis- black woman, to pray and keep her “family busi- tinctions between these groups and their ethnic ness” to herself. She expressed her mistrust of “the subgroups. system” and therapy but never missed a session. She vacillated between appearing indifferent to Among the most notable distinctions between highly anxious to somewhat combative. It was only groups is that African slaves were disconnected after six months of treatment and discussions about from their ethnic, geographical, linguistic, and the old neighborhood that she disclosed years of cultural communities by slavery and discrimi- physical torture, as well as sexual abuse by her drug-dealing step-father. She described how she nated against in America based on racial charac- would hide the rope burns on her wrists with brace- teristics. As such, African-American identity has lets because she didn’t want to give her mother been shaped largely by racial identity rather than more problems than she already had in this “racist ethnic identity. On the other hand, voluntary place.” African immigrants have strong connections to Approximately 13% of US residents self-identify ethnic, geographical, cultural, and linguistic as Black (U.S. Census Bureau, 2016). Since the communities in Africa. Therefore, many have year 2000, the number of Black immigrants living called into question the meaning and accuracy of in the country has increased by 71%. Almost one the terms “Black” and “African-American” in ten Blacks (9%) living in the USA are foreign (Alex-Assensoh, 2009). As with all people the born. Africans constitute 39% of the overall for- intersectionality of class, gender, and residential 260 A. Torres et al. patterns may also make a difference in a person’s Disparity examines the difference in relation overall identity. Many ethnographic studies note to outcomes experienced based on race and eth- the attempts by Black immigrants to distinguish nicity (Casey Foundation, 2018). The two most themselves from—and avoid the stigma associ- salient examples of disparity are related to child ated with—poor African-Americans (Alex-welfare and criminal justice involvement (Nellis, Assensoh, 2009). 2016). For example, research has indicated that racial disparities occur at several, decision points in the child welfare process (e.g., Detlaff et al., Trauma Exposure in the Black 2011; Font, 2013; Putnam-Hornstein, Needell, Diaspora King, & Johnson-Motoyama, 2013). African- Americans account for 15% of all children in the Roberts et al. (2011) large national study found USA, yet they account for 25% of substantiated that Blacks had higher lifetime prevalence of maltreatment victims. Disparities are even more PTSD and experienced higher levels of violent pronounced when it comes to out-of-home care victimization than other racial/ethnic groups. as African-American children represent 45% of They stipulate that perceived discrimination, the total number of children in foster care (Casey race-related verbal assault, and racial stigmati- Foundation, 2018). This factor alone may have zation have been linked to PTSD symptoms and the potential of increasing their risk of future may partially account for the higher conditional traumatic experiences. Another example of the risk of PTSD among Blacks. The Centers for impact of disparity is that African-Americans are Disease Control (CDC, 2017) indicates that incarcerated in state prisons at rates that are over homicide is the number one killer of Black five times the imprisonment of Whites, and in males ages 10–35, whereas Black females are some states the disparity is more than ten to one four times more likely to be murdered by a sig- (Nellis, 2016). nificant other than their White counterparts As in many of the other diasporas previously (Weiss et al., 2015). As such, they are dispropor- covered in this chapter, Black immigrants may tionally victims of these types of violence. present with premigration trauma exposure. It Disproportionality refers to the representation of should be noted that several African countries are their group being larger or smaller than the same considered among the most violent in the world group’s representation in the general population due to political instability, including the (Casey Foundation, 2018). One potential expla- Democratic Republic of Congo Libya, Somalia, nation for this disproportionality may be socio- Sudan, Nigeria, Ethiopia, Kenya, and Chad economic status. Both Latinx and Black (Institute for Economics and Peace, 2017). immigrants are often at a much greater risk for poverty as compared to immigrants from Europe, Canada, or Asia (Mather, 2009). As a Trauma Symptoms in African/Blacks result of their lower socioeconomic status, African-Americans in the USA are often forced Research exploring trauma-related differences to live in areas that increase their risk of expo- within the Black diaspora is nonexistent (Pole sure to trauma, violence, and stress (Martinez, et al., 2008). One study of African-Americans 1996; Roberts et al., 2011; Shihadeh & Flynn, with PTSD symptoms found that perceived 1996; Williams & Williams-Morris, 2000). racial discrimination was associated with more Individuals from low-resource neighborhoods severe PTSD symptoms (Pole et al., 2005). It is may present with daily living issues exacerbated important to consider the role of racism in the by inaccessible or poor health care, reduced perpetuation of the violent environment and how social or community support, as well as high an exploration of this may help clients have a crime and violence rates (Reardon, Fox, & different perspective. For example, this may Townsend, 2015). impact their views on the effects of gang vio- 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview 261 lence, intimate partner violence/child maltreat- tion, have led to multigenerational maladaptive ment, and police use of excessive force, and this behaviors in response to trauma. The key PTSS work attempts to highlight the repercussions of patterns that she describes are a marked propen- violence in the African-American community. A sity for anger and violence stemming from large-scale study using data from the National extreme feelings of suspicion of the perceived Survey of African Life (NSAL) found that 87% negative motivation of others. She also describes of African-American youth and 90% of a racist socialization which leads to internalized Caribbean Black youth indicated that they had racism. These symptoms are reminiscent of experienced at least one discriminatory incident symptom presentations of mistrust and self- in the past year (Seaton, Caldwell, Sellers, & blame that are common in interpersonal trauma. Jackson, 2008). Carter (2016) theorizes that high However, this concept has not been without its rates of PTSD for Blacks may be related to or criticism. For example, Kendi (2016) contends increased by racial discrimination. Trauma that PTSS is a more progressive racist theory that researchers have eluded to this association, but it roots “dysfunctional” Black behaviors in the his- has not been a focus of research (Carter et al., tory of oppression instead of biological or cul- 2017; Loo, Fairbank, & Chemtob, 2005). Prior tural factors. Nonetheless, it is a very important to the introduction of the race-based traumatic concept to consider in terms of how our clients stress (RBTS) model, there was no specific link view themselves and whether anger/hostility to an experience of racism and symptoms should be considered in the context of trauma (Carter, 2016; Carter & Sant-Barket, 2015). instead of as an externalizing disorder. Carter (2016) has proposed that research dem- Of note there are a number of cultural-bound onstrates a connection between racial discrimina- syndromes originating in West Africa, Haiti, and tion and a subsequent trauma response, including the African-American Southern United States. A severe stress reactions (Carter, 2016; Carter, number of these syndromes (e.g., maladi moun, Forsyth, Mazzula, &Williams, 2005). In support rootwork, and zār) have a strong, external spiri- of this RBTS model, Bryant-Davis and Ocampo tual or magical component. There is a cultural (2005) found that while not all ethnic minorities notion that spirits or hexes can impact health. who experience racist incidents will exhibit post- Caribbean and African groups may attribute traumatic symptoms, many present with intense symptomatology to the possession by a spirit or fear, anxiety, helplessness, reexperiencing the by a hex/curse placed by another individual. event, and avoidance in response to racial inci- Rootwork is referred to the traditional medicine dents. Carter et al. (2013) developed the Race- of Black Americans that has its origins in slave Based Traumatic Stress Symptom Scale to assess culture of the South. Its continued influence on the prevalence and severity of psychological and the health behavior of Black Americans is emotional stress reactions to memorable encoun- reported for rural areas of the South and for poor ters of racism and racial discrimination. Similarly, urban areas throughout the USA. The rootwork Ken Hardy (2013) described “race-related trauma system combines a belief in the magical causa- wounds, such as internalized devaluation, tion of illness with cures by sorcery and an assaulted sense of self, internalized voiceless- empiric tradition stressing the natural causation ness, and the wound of rage in African-American of illness with cures by herbs and medicines clients.” (Matthews, 1987). On a related vein, DeGruy (2005) conducted “Falling out” or “blacking out” refers to a cul- years of psychological research on the multigen- turally bound syndrome that could potentially be erational trauma experienced by African-associated with a traumatic experience. It is most Americans. The term “Posttraumatic Slave commonly reported in the Southern United States Syndrome (PTSS)” was coined in her book that and the Caribbean. The syndrome entails a con- theorizes that centuries of slavery, systemic rac- stricted consciousness in which a person can see ism, and oppression, including mass incarcera- and hear but not act. The DSM had described it as 262 A. Torres et al. a sudden collapse, which sometimes occurs with- teract the research that suggests the research that out warning, but sometimes preceded by feelings African-Americans have a less positive attitude of dizziness or “swimming” in the head (DSM- toward mental health treatment after utilizing ser- IV-TR: American Psychiatric Association, 2000, vices (Diala et al., 2000). p. 900). Similar to other idioms of distress, there is a feeling of loss of control of one’s body. Conclusion: General Treatment Implications Treatment Guidelines for Working with Blacks and African-Americans A wealth of research has shown that therapist integration of client’s cultural narratives in inter- Overall, the experience of racial oppression has a vention and the client’s perceptions of how a significant impact on the manifestation of trauma therapist navigates cultural factors in treatment in Black and African-Americans. It is important are correlated with outcome (Benish et al., 2011; for these racially discriminatory experiences to Bernal & Adames, 2017; Griner & Smith, 2006; be acknowledged and validated so that they can Smith, Domenech-Rodriguez, & Bernal, 2011; resist oppressive environments and internalized Tao, Owen, Pace, & Imel, 2015). In a similar oppression (Jernigan, 2009; Jernigan & vein, several books have been written addressing Henderson-Daniel, 2011; Nicolas et al., 2008). the impact of culture on trauma (Brown, 2008; Without the direct exploration of these concepts, Hinton & Good, 2018; Rhoades & Sar, 2005). we cannot fully engage all of the aspects of a This chapter attempted to succinctly explore the traumatic experience. Therapists may believe existing research regarding how cultural factors that discrimination only occurs in other systems. may play a role in trauma exposure risk, symp- However, the prevalence of racial/ethnic micro- tom presentation, and views about healing. The aggressions in therapy is relatively high, with following list contains general recommendations 53–81% of clients reporting experiencing at least for clinicians who are working with clients across one microaggression (Hook et al., 2016). Blacks cultural groups: and Latinx groups share a history of colonization and oppressed status that may also impact their 1. Start from a strengths-based, culturally willingness to share information. Yet discrimina- respectful and curious perspective. tion is a factor that is often overlooked in clinical 2. Promote cultural protective factors to reduce settings. disparities in outcomes (e.g., ethnic identity, Discrimination experiences have a profound spirituality). impact on the person’s narrative regarding the 3. Welcome cultural adaptations and culturally traumatic experience and/or their sense of self. appropriate models of explaining “illness.” Many of our therapeutic approaches do not 4. Understand that treatment should be symptom- address aspects of discrimination and power or specific and culturally guided instead of tech- privilege within the therapeutic exchange. nique- or diagnosis-specific, especially when However, it has been found that minorities who working with clients with comorbidity and strongly identify only with their ethnic group and acculturative stress. not the dominant group may perceive greater 5. Obtain some basic immigration-related stigma and discrimination are more likely to knowledge if providing services to undocu- report greater PTSD symptom severity (Breslau, mented individuals. Clinicians should be able 2002; Galea et al., 2004; Khaylis, Waelde, & to provide clients information about local Bruce, 2007; Loo et al., 2001). If therapists immigrant rights groups and lawyers that explored racial and ethnic identity, as well as could assist undocumented clients who have spiritualty beliefs, it could potentially help coun- experienced trauma and abuse. Many undocu- 18 Cross-Cultural Factors in the Treatment of Trauma-Related Disorders: Overview 263

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Frances R. Gonzalez

Social Anxiety Disorder: Prevalence Medical School, 2007b). Among various coun- and Correlates tries the onset of SAD occurs mid-late adolescent years and early 40s (Stein et al., 2017). Previously termed social phobia, social anxiety Additionally, individuals with SAD were at disorder (SAD) is the persistent fear and anxiety higher risk for comorbidity of another mental ill- in one or more social or performance situations in ness (80%; Stein et al., 2017). Individuals with a which an individual may be exposed to scrutiny psychotic disorder are at higher risk of experienc- or negative evaluation by others (DSM 5, ing SAD, with prevalence rates between 8% and American Psychiatric Association, 2013). SAD 22% (McEnery et al., 2019). Worldwide only has been associated with great impairment that 38% of the population with SAD receive treat- reduces the quality of life (McEnery, Lim, ment for symptoms of SAD, which included Tremain, Knowles, & Alvarez-Jimenez, 2019). medical, mental, and nontraditional healthcare SAD is prevalent worldwide with Nigeria and (Stein et al., 2017). China having the lowest prevalence rates of SAD and Australia, New Zealand, and the USA reporting the highest lifetime prevalence rates (Stein Social Anxiety Among Latinxs et al., 2017). Notably, countries with higher incomes are more likely to report higher preva- Anxiety disorders affect an estimated 21% of the lence rates of SAD than counties that have lower Latinx population (Breslau, Kendler, Su, Gaxiola- incomes (Stein et al., 2017). In the USA it is esti- Aguilar, & Kessler, 2005). The exact number of mated that about 7% of adults aged 18 years or Latinxs with SAD is not noted in the literature older had social anxiety in the past year (Harvard since all anxiety disorders are typically grouped Medical School, 2007a), while about 13% of US under one term, anxiety disorders. A study by adults had experienced SAD in their lifetime Bjornsson et al. (2014) examined the clinical (Kessler, Petukhova, Sampson, Zaslavsky, & characteristics and demographic variables of a Wittchen, 2012). In the USA, SAD was reported sample of Latinxs with SAD, generalized anxiety higher among females than males with 8% of disorder, or panic disorder with agoraphobia. The females reporting SAD and 6% of males (Harvard majority of Latinxs with SAD reported originating mostly from the USA, Puerto Rico, and the Dominican Republic. The mean onset of SAD F. R. Gonzalez (*) was 13 years old with a duration rate of 21 years. Department of Psychology, University of Nevada, Individuals with SAD had the mean age of Reno, Reno, NV, USA

35 years old, mostly single, female, had some of Caribbean blacks and 43% African Americans college educations, were equally employed and were significantly more likely to report racial fac- unemployed, received income from their job, tors as the primary reason for major discrimina- made less than $20,000 a year, and live alone. tion compared to non-Hispanic whites. Another About 37% of participants with SAD reported a study examined the relationship between stereo- trauma history. Participants were also mostly type confirmation concern among African likely to report a comorbidity with another psy- Americans and NLWs with SAD (Johnson & chological disorder. About 84% of participants Anderson, 2014). Stereotype confirmation con- reported a lifetime utilization of treatment with cern has been defined as a “chronic experience of the majority utilizing individual therapy. uncertainty and apprehension about appearing to confirm as self-characteristic a stereotype about one’s group” (Contrada et al., 2001, p. 1775). The Social Anxiety Among African results indicated that fear of negative evaluation Americans was positively correlated with stereotype confirmation concern (Johnson & Anderson, 2014). In Anxiety disorders affect an estimated 25% of the summary results from empirical studies suggest African American population (Breslau et al., individuals who are more racially diverse may 2005). While the exact number of African experience more stereotype confirmation Americans with SAD has not been documented concern. in the empirical literature, cultural implications Familial context for African Americans may as they pertain to SAD among African Americans also be associated with SAD among this group. have been discussed. For example, Sibrava et al. Levine, Taylor, Nguyen, Chatters, and Himle (2013) examined the clinical characteristics and (2015) found that among African Americans and demographic variables of a sample of African Black Caribbeans who have close supportive ties Americans with SAD, generalized anxiety disor- with family and friends may be protected against der, or panic disorder with agoraphobia. They developing SAD. However, if individuals had found that the mean onset of SAD was 14 years negative interactions with family (e.g., conflicts), old with a duration rate of 28 years. Individuals they are at an increased risk for meeting criteria in their sample who had SAD had a mean age of for SAD (Levine et al., 2015). African Americans 42 years old and were mostly single, female, had who are not close to their family and experience some college educations, were unemployed, negative interactions with their family are at an received income from psychiatric disability, increased risk of developing SAD (Levine et al., made less than $20,000 a year, and lived alone. 2015). For Caribbean Blacks, the odds of meet- Approximately 57% of participants with SAD ing criteria for SAD were higher among Black reported a trauma history. Participants were also Caribbeans who had high negative interaction most likely to report a comorbidity with another with family as well as low levels of friendship psychological disorder. Approximately 95% of closeness (Levine et al., 2015). participants reported a lifetime utilization of treatment with the majority utilizing individuals’ therapy. Summary When examining the factors that may influence the development of SAD among African An extensive review of the literature revealed that Americans, Levine et al. (2014) indicated that research on SAD among certain cultural groups everyday discrimination (but not major experi- (i.e., Asians, Native Americans) is minimal. ences of discrimination) are associated with SAD There is some literature on Asians and SAD; for African Americans, Caribbean blacks, and however, it discusses the cultural differences in non-Latinx whites (NLW). Approximately 42% SAD between Eastern (especially Japanese, 19 Cultural Considerations in Behavioral Health Service Delivery for Social Anxiety 273

Korean, and Chinese) and Western (US American pies are designed to gradually encourage the and European) samples (Choy, Schneier, individual to enter feared social situations and Heimberg, Oh, & Liebowitz, 2008; Hofmann, try to remain in those situations (Forman & Asnaani, & Hinton, 2010). For example, Japanese Kaye, 2016). Individual therapy is most fre- and Koreans use the term taijin kyofusho (TKS) quently used but cognitive behavioral therapy to describe culturally specific SAD (Choy et al., has been effective among diverse groups such as 2008). More specifically TKS is focused on an Latinos with anxiety disorders (Chavira et al., individual doing something that will embarrass 2014). Additionally, CBT in group format the other person, which in contrast to SAD (CBGT) has also been effective among diverse focuses on embarrassing oneself (Choy et al., populations (Graham-LoPresti et al., 2017; 2008). While there is some research on the Latinx Leichsenring & Leweke, 2017). The standard population, the research is limited although it is group protocol is 12–16 sessions, with each clear that Latinxs are affected by SAD. As sum- group session lasting 2.5 h (Hoffman & Otto, marized above, across the major ethnic minority 2017). According to Hoffman and Otto (2017), groups in the USA, the bulk of the research has the sessions are formatted in the following way: been conducted with African Americans. Further research is needed to understand the prevalence • Session 1: Establish rapport, make group rates of SAD among diverse groups in the USA members comfortable with a socially chal- so as to establish risk and protective factors in the lenging situation, and provide treatment ratio- development and maintenance of SAD. As noted nale, with attention to the structure of exposure with the studies on African Americans, discrimi- practice. A fear and avoidance hierarchy is nation or marginalization impacts SAD, but little created with the most feared and avoided is known about the impact of discrimination or social situations. Clients are assigned home- marginalization among other diverse groups with work where they are to perform behaviors or SAD. There are various treatments that can be place themselves in situations that were previ- used with individuals with SAD, but CBT is usu- ously avoided or tolerated only with excessive ally the first line of treatment, and CBT has been anxiety. adapted to be used with individuals who are cul- • Session 2: Briefly review past weeks’ topic. turally diverse. Review of home practice from the past week by identifying anxiety-provoking aspects of the situations. Examine perceptions of control Treatment Options for SAD: over anxiety, and examine self-focus and self- Cognitive Behavioral Therapy (CBT) perception. Identify safety behaviors and other avoidance strategies. Explore post-event rumi- Cognitive behavior therapy is effective for reduc- nation. Clients will conduct in-session expo- ing psychological distress among a range of sures, by conducting a speech performance. populations with various disorders including Clients will be assigned home practice. social anxiety disorder (Hofmann, Asnaani, • Sessions 3–6: Clients continue to do numer- Vonk, Sawyer, & Fang, 2012). CBT for social ous trials of speech exposures. The topics anxiety involves restructuring negative thoughts should be adapted to each client. The clients and having the client experience exposures in continue to be given home practice assign- social contexts (Graham-LoPresti, Gautier, ments, for example, speaking in front of a mir- Sorenson, & Hayes-Skelton, 2017). More spe- ror about a random topic and to audiotape one cifically, CBT techniques focus on modifying of the speeches. the catastrophic thinking patterns and beliefs • Session 7 till the last session: In vivo exposure that social failure and rejection are likely situations are assigned for outside of the (Forman & Kaye, 2016). CBT exposure thera- group. Each situation should be individually 274 F. R. Gonzalez

tailored to the client and should be based on nation and prejudice on anxiety for individuals of the fear and avoidance hierarchy. A relapse color. The results from the case study indicated prevention segment should be included in the that the individuals scores decreased significantly final session. Summary of progress of each and no longer met criteria for SAD posttreatment group member should be conducted. Booster and during the follow-up. Additionally, the par- sessions can be offered if needed. ticipant reported having positive experiences, especially with the integration of marginalization Graham-LoPresti et al. (2017) adapted the (Graham-LoPresti et al., 2017). Exploring treat- CBGT protocol to be culturally sensitive. The ments that aim at targeting marginalization or authors assessed outcomes from the adapted stereotype confirmation concern in addition to CBGT using a case study. In addition to the 12 other social experiences may be beneficial for sessions of the group therapy, the authors added a individuals who have SAD. All goals could be therapist engagement session. The purpose of met with a culturally adapted cognitive behav- this session was to obtain a better understating of ioral therapy. the client’s race, ethnicity, gender, sexuality, dis- Stereotype confirmation concerns have also ability, and class (Graham-LoPresti et al., 2017). been noted to be related to treatment. Johnson, In the study during the engagement session, ther- Price, Mehta, and Anderson (2014) found that apists were trained to ask clients about their stereotype confirmation concerns were associ- experiences of marginalization and/or discrimi- ated with higher dropout rates of treatment. nation in their life context and the ways that these African Americans were more likely to drop out experiences have (or have not) contributed to of treatment compared to NLWs, specifically if their experience of SAD. Previous research has they were in the cognitive behavioral therapy shown marginalized groups can experience sepa- exposure group versus the virtual reality group ration or exclusion from mainstream society, (Johnson et al., 2014). The authors suggest that poor treatment, poor access to resources, and individuals who are African American may fear overall social devaluation which can contribute to endorsing negative stereotypes of their group the development and maintenance of SAD (Johnson et al., 2014). Being in a group setting (Graham-LoPresti et al., 2017; Sue, 2010). Using may increase stereotype confirmation concerns cognitive restructuring marginalized groups can specifically if group members are not African focus on restructuring internalized experiences, American. such as discrimination (Graham-LoPresti et al., 2017). During the in-session exposure segment of the adapted CBGT, the clients’ exposures Recommendations for Working included exercises that addressed anxiety due to with Clients with Social Anxiety marginalization experiences. For the in-between Disorder session, the clients’ assignment encouraged them to interact with groups they felt marginalized by. There are no clear clinical practice guidelines The culturally adapted treatment focused on mar- developed for working with people with SAD, ginalization and discrimination positively especially for individuals from diverse back- impacted other members in the group. Using grounds. The National Institute for Health and examples of discrimination allowed group mem- Care Excellence (2013) developed recommenda- bers of color to note if they too experienced such tions for working with clients with SAD. There issues and the examples were also a teachable are 18 recommendations and below are a few of moment for White identified group members to them (full list can be found at https://www.nice. learn about the impact of experiences of discrimi- org.uk/guidance/cg159): 19 Cultural Considerations in Behavioral Health Service Delivery for Social Anxiety 275

• Be aware that people with social anxiety dis- –– conduct an assessment that considers fear, order may: avoidance, distress, and functional –– not know that social anxiety disorder is a impairment recognized condition and can be effectively –– be aware of comorbid disorders, including treated avoidant personality disorder, alcohol and –– perceive their social anxiety as a personal substance misuse, mood disorders, other flaw or failing anxiety disorders, psychosis, and autism. –– be vulnerable to stigma and embarrassment –– avoid contact with and find it difficult or Summary distressing to interact with healthcare professionals, staff, and other service users There are not many clear guidelines and princi- –– avoid disclosing information, asking and ples in working with diverse clients who have answering questions, and making SAD. If a therapist, psychologist, or researcher is complaints interested in working with the individuals with –– have difficulty concentrating when infor- SAD, knowledge of the diverse social stressors mation is explained to them. being faced by those individuals is important. • Consider arranging services flexibly to pro- The therapist needs to be aware of their limita- mote access and avoid exacerbating social tions and own biases. Seeking additional anxiety disorder symptoms by offering: resources from the community and other thera- –– appointments at times when the service is pists is always recommended by the general psy- least crowded or busy chological guidelines and principles. Since the –– appointments before or after normal hours, USA continues to grow in diversity, therapists or at home initially working with individuals with SAD should –– self check-in and other ways to reduce dis- become more familiar with social stressors such tress on arrival as experiences with discrimination or –– opportunities to complete forms or paper- marginalization. work before or after an appointment in a private space support with concerns related to social anxiety (for example, using public References transport) –– a choice of professional if possible. American Psychiatric Association. (2013). Diagnostic and • When assessing a person with social anxiety statistical manual of mental disorders (5th ed.). https:// doi.org/10.1176/appi.books.9780890425596 disorder: Bjornsson, A., Sibrava, N., Beard, C., Moitra, E., –– suggest that they communicate with you in Weisberg, R., Benitez, C., & Keller, M. (2014). Two- the manner they find most comfortable, year course of generalized anxiety disorder, social including writing (for example, in a letter anxiety disorder, and panic disorder with agoraphobia in a sample of Latino adults. Journal of Consulting or questionnaire) and Clinical Psychology, 82(6), 1186–1192. https:// –– offer to communicate with them by phone doi.org/10.1037/a0036565 call, text, and email Breslau, J., Kendler, K. S., Su, M., Gaxiola-Aguilar, S., –– make sure they have opportunities to ask & Kessler, R. C. (2005). Lifetime risk and persistence of psychiatric disorders across ethnic groups in the any questions and encourage them to do so United States. Psychological Medicine, 35, 317–327. –– provide opportunities for them to make and https://doi.org/10.1017/S0033291704003514 change appointments by various means, Chavira, D., Golinelli, D., Sherbourne, C., Stein, M., including text, email, or phone. Sullivan, G., Bystritsky, A., … Craske, M. (2014). Treatment engagement and response to CBT among • When assessing an adult with possible social Latinos with anxiety disorders in primary care. anxiety disorder: Journal of Consulting and Clinical Psychology, 82(3), 392–403. https://doi.org/10.1037/a0036365 276 F. R. Gonzalez

Choy, Y., Schneier, F. R., Heimberg, R. G., Oh, K., & Johnson, S., Price, M., Mehta, N., & Anderson, P. (2014). Liebowitz, M. R. (2008). Features of the offensive sub- Stereotype confirmation concerns predict dropout type of Taijin-Kyofu-Sho in US and Korean patients from cognitive behavioral therapy for social anxiety with DSM-IV social anxiety disorder. Depression disorder. BMC Psychiatry, 14(1), 233. https://doi. and Anxiety, 25(3), 230–240. https://doi.org/10.1002/ org/10.1186/s12888-014-0233-8 da.20295 Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, Contrada, R. J., Ashmore, R. D., Gary, M. L., Coups, A. M., & Wittchen, H. (2012). Twelve-month and life- E., Egeth, J. D., Sewell, A., … Goyal, T. M. time prevalence and lifetime morbid risk of anxiety (2001). Measures of ethnicity-related stress: and mood disorders in the United States. International Psychometric properties, ethnic group differences, Journal of Methods in Psychiatric Research, 21(3), and associations with well-being. Journal of Applied 169–184. https://doi.org/10.1002/mpr.1359 Social Psychology, 31, 1775–1820. https://doi. Leichsenring, F., & Leweke, F. (2017). Social anxiety dis- org/10.1111/j.1559-1816.2001.tb00205.x order. The New England Journal of Medicine, 376(23), Forman, E., & Kaye, J. (2016). Diagnosis: Social anxiety 2255–2264. https://doi.org/10.1056/NEJMcp1614701 disorder and public speaking anxiety. Retrieved from Levine, D., Himle, J., Abelson, J., Matusko, N., Dhawan, https://www.div12.org/treatment/cognitive-behav- N., & Taylor, R. (2014). Discrimination and social anx- ioral-therapy-for-social-anxiety-disorder/ iety disorder among African-Americans, Caribbean Graham-LoPresti, J. R., Gautier, S. W., Sorenson, S., & blacks, and non-Hispanic whites. Journal of Nervous Hayes-Skelton, S. A. (2017). Culturally sensitive and Mental Disease, 202(3), 224–230. https://doi. adaptations to evidence-based cognitive behavioral org/10.1097/NMD.0000000000000099 treatment for social anxiety disorder: A case paper. Levine, D. S., Taylor, R. J., Nguyen, A. W., Chatters, Cognitive and Behavioral Practice, 24(4), 459–471. L. M., & Himle, J. A. (2015). Family and friendship https://doi.org/10.1016/j.cbpra.2016.12.003 informal support networks and social anxiety disor- Harvard Medical School. (2007a). National Comorbidity der among African Americans and black Caribbeans. Survey (NCS). Retrieved from https://www.hcp.med. Social Psychiatry and Psychiatric Epidemiology, harvard.edu/ncs/index.php. Data Table 2: 12-month 50(7), 1121–1133. https://doi.org/10.1007/ prevalence DSM-IV/WMH-CIDI disorders by sex and s00127-015-1023-4 cohort. McEnery, C., Lim, M. H., Tremain, H., Knowles, A., Harvard Medical School. (2007b). National Comorbidity & Alvarez-Jimenez, M. (2019). Prevalence rate of Survey (NCS). Retrieved from https://www.hcp.med. social anxiety disorder in individuals with a psychotic harvard.edu/ncs/index.php. Data Table 1: Lifetime disorder: A systematic review and meta-analysis. prevalence DSM-IV/WMH-CIDI disorders by sex and Schizophrenia Research, 208, 25–33. https://doi. cohort. org/10.1016/j.schres.2019.01.045 Hoffman, S. G., & Otto, M. W. (2017). Cognitive behav- National Institute for Health and Care Excellence. (2013). ioral therapy for social anxiety disorder: Evidence- Social anxiety disorder: Recognition, assessment and based and disorder specific treatment techniques. treatment. Retrieved from https://www.nice.org.uk/ New York, NY: Routledge. guidance/cg159 Hofmann, S. G., Asnaani, A., & Hinton, D. E. (2010). Sibrava, N., Beard, C., Bjornsson, A., Moitra, E., Cultural aspects in social anxiety and social anxiety Weisberg, R., & Keller, M. (2013). Two-year course disorder. 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Holly Hazlett-Stevens

Introduction assessment and treatment of anxiety in general, followed by an introduction to mindfulness inter- As the evidence base for mindfulness-based vention approaches and a review of clinical prac- interventions (MBIs) grows, clinicians increas- tices expected to maximize culturally sensitive ingly are turning to this approach to treat anxiety delivery of MBIs among diverse individuals. disorders and anxiety-related symptoms. Indeed, randomized controlled trials not only support the use of MBIs to alleviate anxiety and stress-related Cultural Aspects of Anxiety symptoms in medical populations, but MBIs have Disorders demonstrated effectiveness for diagnosed anxiety disorder clinical presentations as well. More and Anxiety Disorders Among Latinx more patients seeking treatment for anxiety dis- Individuals orders in the USA are culturally, ethnically, and racially diverse, and while a growing body of Latinx Americans represent not only the largest research has identified important clinical consid- but also the fastest-growing, ethnic minority erations when serving diverse patients presenting group in the USA (U.S. Bureau of the Census, with anxiety disorders, much of this research is 2010). For this reason, clinical researchers limited to cognitive behavioral therapies (CBTs). increasingly have examined cultural influences Research addressing culturally sensitive on anxiety disorder symptom expression, diag- mindfulness-based behavioral health care for nosis, and treatment outcomes while developing anxiety disorders is sparse. This paucity of infor- culturally sensitive treatment adaptation guide- mation is especially problematic because MBIs lines for Latinx patients. Although some epide- originated from ancient Buddhist meditation miological studies reported comparable practices rooted in Eastern cultures, and it is prevalence rates of anxiety disorders between unclear how culturally diverse individuals living Latinx and non-Latinx White individuals in the West perceive secular mindfulness medita- (Kessler, Chiu, Demler, & Walters, 2005), Latinx tion instructions. The current chapter provides a individuals tend to report greater persistence in brief overview of cultural considerations in the anxiety symptoms (Breslau, Kendler, Su, Aguilar-Gaxola, & Kessler, 2005) and more H. Hazlett-Stevens (*) severe functional impairment from anxiety Department of Psychology, University of Nevada, (Moitra et al., 2014). Furthermore, anxiety Reno, NV, USA symptoms among Latinx individuals increase e-mail: [email protected]

© Springer Nature Switzerland AG 2020 277 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_20 278 H. Hazlett-Stevens with higher rates of acculturation (Alegría et al., The stigma of seeking help from a mental health 2008) and with greater acculturative stress and professional (Azocar, Areán, Miranda, & Muñoz, discrimination (Berkel et al., 2010; Finch, 2001) is one possible reason that Latinx patients Kolody, & Vega, 2000). Latinx patients more often prefer to seek such services from medical often report somatic expressions of anxiety providers over mental health specialty providers (Canino, Rubio-Stipec, Canino, & Escobar, or agencies (Vega, Kolody, & Aguilar-Gaxiola, 1992) and/or higher levels of somatization 2001). Nevertheless, outside the clinical trials (Escobar, Gomez, & Tuason, 1983), which may research context, Latinx individuals are less likely reflect a common expression of emotional and than their non-Latinx White counterparts to use social distress within one’s cultural context mental health services (Alegría et al., 2002), and (Kirmayer & Young, 1998). Culturally specific this disparity is further pronounced for less accul- anxiety syndromes include ataque de nervios turated immigrants (Alegría et al., 2007). found in Puerto Rican and Dominican cultures, A number of factors appear to contribute to characterized by a dramatic increase in physio- the disparity in quality behavioral health care for logical arousal and negative affect in response to anxiety disorders found between Latinx and non- a significant stressor that often is accompanied Latinx White groups. Anxiety symptoms are less by a fear that one might faint, may be dying, or frequently detected among racial and ethnic will engage in destructive behavior due to a lack minority primary care patients (Stockdale, of control (Hofmann & Hinton, 2014). Lagomasino, Siddique, McGuire, & Miranda, Escovar et al. (2018) examined baseline data 2008), possibly due to: from a large (N = 764) clinical trial of adult primary care patients seeking treatment for anxiety 1. a lack of culturally informed screenings disorders to determine how Latinx and non-Latinx (Barrios, Blackmore, & Chavira, 2016), White ethnic group differences, as well as within- 2. mismatches between DSM diagnostic criteria group Latinx cultural variables, related to clinical and culturally specific symptom expression characteristics. Although rates of anxiety disorder compromising the validity of DSM diagnosis diagnosis, symptom severity levels, anxiety sensi- across cultures (Lewis-Fernández et al., tivity, and mental functional impairment were 2010), and/or comparable between the two ethnic groups, the 3. perceptions of racial discrimination reducing Latinx group reported a higher average number of patient willingness to endorse anxiety disorder anxiety disorders, greater somatization, and symptoms (Asnaani, Richey, Dimaite, Hinton, increased physical functional impairment com- & Hofmann, 2010) and major depressive dis- pared to the non-Latinx White group. Within the order and substance use disorder symptoms Latinx group, perceived discrimination was the (Chou, Asnaani, & Hofmann, 2012). only cultural variable that predicted mental health symptoms while controlling for other demo- Even when psychological disorders are diag- graphic variables. Importantly, this investigation nosed among Latinx individuals, evidence-based was conducted in a primary care medical facility, psychotherapies are less likely to be delivered the type of clinical setting in which Latinx patients (Stockdale et al., Young, Klap, Sherbourne, & most often seek mental health treatment (Vega & Wells, 2001), and practical barriers to access Lopez, 2001). When Latinx patients do seek such such as the inability to secure time off work, lack treatment, they tend to obtain mental health care of available time for therapy, the need for child- in primary care medical clinics despite a lower care, and inadequate transportation exist (see likelihood to believe that mental health symptoms Barrios et al. for a review). In their review of this are biologically based and an increased likelihood literature, Barrios et al. concluded that although of believing that counseling approaches are effec- Latinx individuals in the USA are at heightened tive and preferable to medication (Givens, risk for developing anxiety disorders and suffer Houston, Van Voorhees, Ford, & Cooper, 2007). poorer odds of receiving quality assessment and 20 Cultural Considerations When Treating Anxiety Disorders with Mindfulness-Based Interventions 279 treatment, evidence-based CBTs generally yield anxiety found in Japanese and Korean cultures in favorable outcomes for Latinx patients, espe- which the individual is concerned about acting in a cially when adaptations improve their engage- way that offends or embarrasses others instead of ment in mental health treatment. oneself. A variety of effective evidence-based behavioral and cognitive-behavioral therapies for anxi- Anxiety Across Other Cultures ety disorders exist, and early cross-cultural outcome research investigations supported the Comparisons of anxiety disorder phenomena delivery of these treatments to ethnic/racial across other minority ethnic/racial and cultural minority patients (Schraufnagel, Wagner, groups also have been conducted. Asnaani et al. Miranda, & Roy-Byrne, 2006). A more recent (2010) reported anxiety disorder prevalence rates comprehensive review of this literature (Carter, within a large US sample of Latinx/Hispanic Mitchell, & Sbrocco, 2012) revealed that Latinx/ Americans (N = 3615), Asian Americans Hispanic Americans and Asian Americans gener- (N = 1628), African Americans (N = 4598), and ally enjoyed favorable treatment outcomes for White Americans (N = 6870). After controlling for panic disorder and/or PTSD symptoms that other demographic variables, Asian Americans tended to be equivalent across ethnic/racial endorsed social anxiety disorder, generalized anxi- groups. In their review of research conducted ety disorder, panic disorder, and post-traumatic with African Americans specifically, Carter et al. stress disorder (PTSD) symptoms less frequently found that exposure with response prevention for than all other ethnic/racial groups, and White obsessive-compulsive disorder was effective for Americans were more likely to endorse symptoms African American patients, who appeared to ben- of social anxiety disorder, generalized anxiety dis- efit from this treatment as much as European order, and panic disorder than all three racial/eth- Americans. CBT was effective for African nic minority groups. African Americans more Americans with PTSD, with some studies show- frequently met diagnostic criteria for post- ing that African American patients benefited traumatic stress disorder when compared to White equally when compared to European Americans. American, Latinx/Hispanic American, and Asian However, other PTSD studies found that: (1) American groups. In their review of how cross- European Americans improved slightly more cultural factors influence anxiety symptom expres- than African Americans, (2) African Americans sion, Hofmann and Hinton (2014) found that dropped out of treatment earlier, and (3) the cultural beliefs about the body’s biology are some- matching of African American patients to times associated with culture-specific syndromes. European American therapists was associated For example, Cambodian individuals may hold with reduced treatment program participation. cultural beliefs that disturbed flow of an air-like CBT for panic disorder also benefitted African substance in the body (termed “inner wind”) American patients. However, results from causes a variety of somatic sensations such as gas- reviewed studies also found that when compared trointestinal distress, muscle soreness, tinnitus, to European American patients: (1) fewer African and/or numbness. Interpretation of these sensa- American patients were rated as improved after tions as potentially catastrophic and capable of treatment, (2) African Americans were more causing great bodily harm results in acute anxiety, symptomatic immediately after treatment and at fear, and symptoms of autonomic arousal. follow-up, and (3) African Americans were less Hofmann and Hinton also identified how social likely to report reductions in comorbid depres- contextual factors, such as individualism/collec- sion. Across ethnic/racial minority groups, Carter tivism, independent/interdependent self-construal, et al. also found evidence that cultural adapta- and gender role identification, may help explain tions, such as ethnic matching of therapist and culture-specific expressions of anxiety. One well- patient, use of interpreters with mental health known example is taijin kyofusho, a form of social experience, and delivering treatment in a familiar 280 H. Hazlett-Stevens nonmedical setting, benefitted patients. Carter 2018a). Practical benefits of the MBI approach et al. further recommended that treatments stem from its short-term and time-limited curri- address any culture-specific experiences and/or cula, easily delivered in medical settings due to beliefs of patients, such as prompting discussion the cross-diagnostic group session design. In this of the experience of being African American in a next section, the development of MBIs and the predominantly European American workplace subsequent outcome research of MBIs for anxi- and addressing cultural beliefs that blocked wind ety disorders are reviewed briefly. causes somatic symptoms among Cambodian refugees. Other recommended cultural adaptations in the anxiety disorders treatment literature Mindfulness-Based Interventions include: (1) adequately educating patients about the therapy process itself, (2) increased clinician Mindfulness-Based Stress Reduction sensitivity to issues of stigma as well as real and/ (MBSR) or perceived discrimination, and (3) active problem solving to address practical barriers to access, Mindfulness training first entered the realm of such as childcare and transportation difficulties Western health care when Jon Kabat-Zinn devel- (Barrios et al., 2016). Hinton and Patel (2017) oped mindfulness-based stress reduction provided several detailed cultural adaptation (MBSR) at the University of Massachusetts strategies when treating anxious-depressive dis- (UMass) Medical School in 1979. Kabat-Zinn tress among ethnic/racial minority and refugee previously worked in his chosen field of molecu- groups from a CBT perspective. They developed lar biology, conducting medical research at their culturally informed transdiagnostic model UMass as he studied and practiced Buddhist to help clinicians understand how symptoms of mindfulness meditation in his private life. As distress develop and are culturally shaped and to Kabat-Zinn observed hospital patients strug- guide clinicians in culturally sensitive CBT treat- gling with the stress of chronic illness and/or ment delivery. suffering negative health effects from stressful Taken together, this preliminary work has life circumstances, he developed an 8-week begun to inform culturally sensitive assessment stress reduction course curriculum to teach and treatment of anxiety disorders and anxiety- patients mindfulness meditation practices in a related distress across several racial, ethnic, and secular format free from Buddhist terminology cultural groups of individuals. Much more and rituals. In 1979, he left his medical research research is needed to investigate both the effec- career to teach this stress reduction program to tiveness of standard treatment approaches among patients at the UMass Medical School. This minority populations and the efficacy of cultural stress reduction curriculum, which Kabat-Zinn adaptations developed for specific groups of indi- eventually named MBSR, centered on cultivat- viduals. Not surprisingly, this research is limited ing mindfulness, defined by Kabat-Zinn as “the to CBT approaches, the most prominent and awareness that emerges through paying attention widely studied treatment approach in the anxiety on purpose, in the present moment, and nonjudg- disorders literature. However, alternative inter- mentally to the unfolding of experience moment vention approaches incorporating mindfulness to moment” (Kabat-Zinn, 2003, p. 145). The training have received increasing empirical sup- word mindfulness is an English translation of the port over recent years. MBIs may offer some ancient Asian Pali word sati, the original word advantages over traditional CBT approaches, used to capture this nonconceptual awareness of including a transdiagnostic conceptual model, experience in Buddhist meditation traditions, demonstrated efficacy to alleviate numerous and sati is considered essential for all forms of comorbid medical and psychological symptoms, Buddhist meditation practice (Nyanaponika and reduced stigma resulting from a public health Thera, 1965). Kabat-Zinn developed MBSR to education delivery format (Hazlett-Stevens, teach the intentional cultivation of mindfulness 20 Cultural Considerations When Treating Anxiety Disorders with Mindfulness-Based Interventions 281 from a universal perspective, viewing mindful- and eventually, mindfulness of stressful events ness as a fundamental human capacity that tran- as they occur in daily life. Participant experi- scends all cultural and religious backgrounds. ences with these informal practices fuel class He therefore adapted several meditation prac- discussion of didactic material topics, such as tices he previously learned in formal Buddhist how mindfulness contrasts with our default meditation training settings in such a way that “automatic pilot” form of attention, the role of meditation instructions are explained in simple perception in stress, and models of stress reac- and secular language while retaining the essence tivity compared to stress responding. As partici- and integrity of the original practices (see Kabat- pants cultivate mindfulness through daily formal Zinn, 2003, 2005 for further descriptions of the meditation/movement practices and increase development of MBSR). mindful awareness over the course of daily liv- MBSR involves 8 weekly class sessions, lasting, they identify habitual patterns of stress ing 2.5–3 h each, and an all-day, 7-h, intensive reactivity across various situations. This process silent meditation retreat held during the week- enables participants to circumvent old reactive end of the sixth week (see Kabat-Zinn, 2013 for habit patterns whenever mindful awareness MBSR procedure descriptions). Weekly ses- allows for more skillful and thoughtful sions begin with 45–90 min of instructor-guided responding. formal mindfulness meditation practice, fol- Early outcome research conducted in Kabat- lowed by group discussion of participant prac- Zinn’s UMass Stress Reduction Clinic sup- tice experiences and interactive presentation of ported the use of MBSR for improving the didactic material. In addition, participants prac- management of chronic pain (Kabat-Zinn, tice daily 40–60-min-long formal mindfulness 1982; Kabat-Zinn, Lipworth, & Burney, 1985). meditation and/or movement home assignments As word spread anecdotally about the benefits with recorded instructions for guidance. Initial of MBSR for medical patients, other clinicians formal meditation practices include a body scan, received training in MBSR instruction and in which participants move the focus of atten- conducted randomized controlled trials. tion throughout each area of the body while Eventually MBSR gained substantial empirical lying still on their backs, and a formal sitting support for the alleviation of perceived stress meditation practice introducing mindfulness of and symptoms of distress associated with breathing instructions. Over the course of the chronic pain, cancer, and other medical condi- MBSR curriculum, sitting meditation instructions (see meta-analytic reviews by Bohlmeijer, tions gradually expand to body sensations, Prenger, Taal, & Cuijpers, 2010; de Vibe, sounds, and thoughts and emotions. Eventually Bjørndal, Tipton, Hammerstrøm, & Kowalski, formal sitting meditation instructions include 2012). Another meta-analysis revealed that “choiceless awareness,” in which present-time MBSR consistently reduced symptoms of anxi- experience itself becomes the object of attention ety and depression across individuals with var- and participants allow awareness of any sensory ious medical and psychiatric conditions and mental experiences as they arise naturally (Hofmann, Sawyer, Witt, & Oh, 2010). In one during the meditation period. In addition, large randomized controlled trial (Biegel, MBSR instructors teach mindfulness during Brown, Shaprio, & Schubert, 2009), 102 ado- movement with formal walking meditation lescent psychiatric outpatients received either instructions and gentle hatha yoga stretches. MBSR coupled with mental health treatment as Throughout the 8-week curriculum, participants usual or mental health treatment as usual only. also engage informal practice assignments out- Outpatients who received MBSR reported side of class sessions, including mindfulness of reduced symptoms of anxiety, depression, eating, mindfulness of everyday activities, somatic distress, and sleep disturbance signifi- mindfulness of pleasant and of unpleasant cantly more than psychiatric treatment-as- events as they naturally occur during the day, usual control group patients did. 282 H. Hazlett-Stevens

MBSR and Anxiety Disorders at follow-up than modified MBSR, while modified MBSR led to greater reductions in worry and MBSR holds promise for anxiety disorder comorbid emotional disorders compared to patients in particular. In an early uncontrolled group-administered CBT. Arch et al. also found study from the original UMass Stress Reduction evidence of equivalent treatment credibility Clinic (Kabat-Zinn, Massion, Kristeller, & between the two interventions, as well as equiva- Peterson, 1992), MBSR participants who initially lent therapist adherence and competency. screened positive for generalized anxiety disor- Randomized controlled trials have been con- der (GAD) and/or panic disorder reported signifi- ducted with clinical samples diagnosed with spe- cant reductions in general anxiety symptoms cific anxiety disorders as well. Participants following MBSR. Acute anxiety symptoms, as diagnosed as GAD following structured clinical commonly measured in clinical panic disorder interviews received MBSR or an active an active research with the Beck Anxiety Inventory, the stress management control intervention (Hoge Fear Survey Schedule, and the Mobility Inventory et al., 2013). The GAD patient group randomized for Agoraphobia, also reduced. These same par- to MBSR yielded greater clinical improvements ticipants reported continued anxiety symptom on clinical severity and improvement clinician improvement 3 years later (Miller, Fletcher, & ratings and self-reported anxiety measures than Kabat-Zinn, 1995). Since then, subsequent ran- the active control group post-intervention, despite domized controlled trials conducted specifically comparable reductions in Hamilton Anxiety with individuals seeking treatment for anxiety Scale symptom ratings. In the laboratory, the disorder symptoms have established the effec- MBSR patients reported greater reductions in tiveness of MBSR for clinical anxiety disorders. subjective anxiety and distress and increased pos- In a mixed clinical sample with diagnoses of itive self-statements in response to a social stress social anxiety disorder, GAD, and/or panic disor- challenge task when compared to the active stress der (Vøllestad, Sivertsen, & Nielsen, 2011), par- management control group. Subsequent uncon- ticipants randomized to MBSR reported trolled research reported significant clinical GAD significant trans-diagnostic anxiety symptom symptom improvement following MBSR in reduction, as well as reduced depression and severe cases, finding that these clinical benefits insomnia, when compared to a wait-list control were not limited to patients reporting only mild group. Another randomized investigation or moderate GAD symptoms (Hazlett-Stevens, included a mixed anxiety disorder sample of vet- 2018b). Furthermore, the substantial GAD symp- eran patients who received a principal diagnosis tom reduction reported in controlled MBSR out- of panic disorder (with or without agoraphobia), come research has been documented outside the GAD, social anxiety disorder, obsessive-controlled research context, in which MBSR was compulsive disorder, or civilian PTSD (Arch delivered as originally designed—that is, to large et al., 2013). Veterans were randomized to a mod- and diagnostically heterogeneous patient groups ified MBSR protocol consisting of 10 weekly in a general hospital setting (Hazlett-Stevens, 1.5-h sessions with a 3-h retreat or to a 10-session 2018a). group-administered CBT in which therapy com- Participants diagnosed with social anxiety ponents could be tailored to individual patients’ disorder and randomized to MBSR or to an aer- specific anxiety disorders. Both modified MBSR obic exercise regimen reported significant and and group-administered CBT significantly equivalent reductions in social anxiety and reduced clinician-rated diagnostic severity of the depression and increased well-being when com- principal anxiety disorder through 3-month fol- pared to an untreated group, immediately after low-up, with no significant differences between intervention and 3 months later (Jazaieri, the two groups. However, results involving self- Goldin, Werner, Ziv, & Gross, 2012). Despite report measures revealed that group-administered equivalent outcomes on symptom measures, CBT led to greater reductions in anxious arousal participants who received MBSR exhibited 20 Cultural Considerations When Treating Anxiety Disorders with Mindfulness-Based Interventions 283 decreased negative self-views and increased Mindfulness-Based Cognitive neural responses in posterior cingulate cortex Therapy (MBCT) and Other MBI areas when compared to the aerobic exercise Protocols group (Goldin, Ziv, Jazaieri, Hahn, & Gross, 2013). In a subsequent trial, social anxiety dis- In the 1990s, another MBI gained attention in order individuals were randomized to MBSR, clinical psychology circles as well. Cognitive cognitive-behavioral group therapy (CBGT), or therapy researchers Zindel Segal, Mark Williams, wait-list control groups (Goldin et al., 2016). and John Teasdale adapted the original MBSR Both MBSR and CBGT produced significant curriculum by integrating elements of cognitive and similar immediate improvements in social therapy and psychoeducation about depression. anxiety symptoms and related clinical measures They developed this mindfulness-based cognitive compared to the wait-list group, although the therapy protocol (MBCT; Segal, Williams, & different interventions impacted some of the Teasdale, 2013) for the specific purpose of pre- specific psychological process measures differ- venting future relapse among individuals recov- entially in expected ways. Importantly, treat- ered from recurrent major depressive episodes. ment gains maintained for both intervention While maintaining the overall group session groups 1 year later. MBSR therefore may yield structure and mindfulness practices of MBSR, social anxiety disorder symptom improvements MBCT targets specific topics such as the self- equivalent to the gold standard CBGT approach, referential nature of thoughts, the role of auto- although a previous comparison of MBSR to matic thought patterns of rumination in the CBGT demonstrated some additional potential development of depression, how cognitive bias benefits of CBGT (Koszycki, Benger, Shlik, & toward negative interpretations impacts emotion, Bradwejn, 2007). Individuals suffering from and how mood influences thoughts and behavior. PTSD also may benefit from MBSR. Veterans MBCT participants also learn a specific informal with PTSD randomized to MBSR reported mindfulness practice, the “3-minute breathing greater improvements in PTSD symptom sever- space,” for use in daily life: throughout the day, ity during treatment and at 2-month follow-up they are encouraged to step out of “automatic than veterans with PTSD randomized to an pilot” mode deliberately by bringing attention to active control present-centered group therapy the breath and then expanding attention to full (Polusny et al., 2015). present-moment experience. In sum, the demonstrated benefits of MBSR MBCT has become a leading evidence-based for anxiety disorder symptom reduction appear group therapy approach in the treatment of more than mere attention placebo effects, and depression. In early randomized controlled clini- MBSR effects do not simply reflect the general cal trials, MBCT significantly reduced the risk of effects of standard stress management education subsequent depressive relapse among patients or exercise. MBSR may be comparable to gold with three or more previous depressive episodes standard CBT protocols, although more research when compared to treatment as usual (Ma & is needed to draw this conclusion. MBSR also Teasdale, 2004; Teasdale et al., 2000). A subse- has the potential to increase dispositional mind- quent meta-analysis found that MBCT signifi- fulness, personal growth, life satisfaction, and cantly reduced the risk of depressive relapse by improved quality of life, thereby enhancing per- 35% overall, and risk reduced by 44% among sonal growth and quality of life beyond anxiety patients with three or more past episodes (Piet & disorder symptom reduction alone (Hazlett- Hougaard, 2011). MBCT also appears effective Stevens, 2018c). Not surprisingly, MBSR among anxiety disorder clinical samples. Anxiety appears in the Substance and Mental Health and comorbid depression symptoms reduced fol- Services Administration (SAMHSA) National lowing MBCT among participants diagnosed Registry of Evidence-based Programs and with generalized anxiety disorder (Craigie, Rees, Practices (NREPP). & Marsh, 2008; Evans et al., 2008) and/or panic 284 H. Hazlett-Stevens disorder (Kim et al., 2009, 2010) as well as social help for anxiety disorder symptoms in the USA, anxiety disorder (Piet, Hougaard, Hecksher, & research including ethnically, racially, and cultur- Rosenberg, 2010). The UK’s National Institute ally diverse clinical samples is needed to repre- for Health and Clinical Excellence (NICE) has sent the diverse US population adequately. endorsed MBCT as an evidence-based therapy. Furthermore, research addressing the acceptabil- Other adaptations of the original MBSR pro- ity and culturally sensitive delivery of MBIs tocol have emerged in the clinical psychology when provided to minority groups is imperative, field. Some protocols targeted clinical problems as is research examining the effectiveness of cul- other than anxiety disorders, such as eating dis- turally adapted MBI protocols. Although this orders (mindfulness-based eating awareness work has not yet appeared within the field of therapy, MB-EAT; Kristeller, Baer, & Quillian- anxiety disorders, MBI clinical researchers work- Wolever, 2006) and substance use (mindfulness- ing with other patient populations have begun to based relapse prevention, MBRP; Witkeiwitz, address these important empirical questions. This Marlatt, & Walker, 2005). However, some prom- next section reviews the emerging literature ising MBIs were tailored specifically for PTSD, informing culturally competent delivery of MBIs. such as mindfulness-based exposure therapy (MBET) developed for veterans (King et al., 2016) and trauma-informed mindfulness-based Mindfulness-Based Interventions: stress reduction (TI-MBSR) developed for survi- Cultural Considerations vors of childhood sexual and physical abuse and/ or intimate partner violence in adulthood (Kelly Implementing MBSR in Diverse & Garland, 2016). In addition, newer individual Communities psychotherapies for anxiety disorders, such as the acceptance-based behavior therapy for GAD Individuals from ethnic, racial, and cultural developed by Roemer and Orsillo (2014), have minority backgrounds are underrepresented in mindfulness practices integrated into their MBI clinical trials, just as these groups are under- protocols. studied in other evidence-based treatment To conclude, MBSR, MBCT, and other MBIs research. DeLuca, Kelman, and Waelde (2018) appear to be promising alternatives to CBT in the further attributed this lack of diversity research to alleviation of anxiety disorder symptoms. the Buddhist origins of MBIs. Because this inter- Importantly, however, it is unclear how well the vention approach is grounded in a Buddhist con- controlled research establishing the effectiveness ceptual perspective that emphasizes the of these MBIs for anxiety disorders generalizes universality of human experience over individual to individuals from diverse backgrounds—the differences, MBI researchers might be less clinical trials described above lacked significant inclined to investigate the role of diversity fac- inclusion of ethnically and racially diverse indi- tors. In addition, knowledge of MBI Buddhist viduals. In some cases, participant samples were origins may cause individuals from diverse back- described as 70–88% non-Hispanic White (Arch grounds concern that the meditation practices et al., 2013; Hoge et al., 2013; Polusny et al., taught in MBIs conflict with their non-Buddhist 2015) or were approximately 40% non-Hispanic religious or spiritual beliefs. Indeed, lower levels White and approximately 40% Asian American of engagement in mindfulness practice were doc- (Goldin et al., 2016; Jazaieri et al., 2012). Other umented among ethnoracial minority groups trials were conducted outside the USA in (Olano et al., 2015). However, it remains unclear Denmark (Piet et al., 2010), Norway (Vøllestad whether this disparity is due to reduced availabil- et al., 2011), and South Korea (Kim et al., 2009) ity of MBIs stemming from the lack of effective- and, therefore, did not report the ethnic or racial ness research conducted with diverse individuals background of participants. As MBIs become or whether MBIs simply appear less acceptable increasingly available to diverse patients seeking to diverse groups of individuals. Nevertheless, 20 Cultural Considerations When Treating Anxiety Disorders with Mindfulness-Based Interventions 285 two MBSR programs implemented in US inner- medical symptoms, health and functioning, and city health clinic settings have begun to explore clinical anxiety. A small subset of participants questions of acceptability and effectiveness of who were willing to complete follow-up mea- MBSR within diverse communities. sures reported that these improvements contin- In 1992, Jon Kabat-Zinn and others from ued up to 7 years later. Kabat-Zinn and colleagues UMass Medical School established a satellite concluded that MBSR can be delivered feasibly MBSR program in a Worcester inner-city neigh- and effectively within a multiethnic and multicul- borhood health clinic to test the feasibility and tural low-income inner-city community, observ- acceptability of MBSR among this underserved ing that the mindfulness practices were culturally and diverse patient population (Kabat-Zinn et al., acceptable in this ethnically diverse population 2016). In contrast to the original UMass program with no prior exposure to meditation methods. that served predominantly White middle- and In 1993, Beth Roth and colleagues imple- working-class patients, many inner-city clinic mented the MBSR curriculum within the inner- patients were Latinx, African American, Native city nonprofit Community Health Center in American, or recent immigrants from various Meriden, CT. By 1997, approximately 200 clinic world regions. Over 60% of the inner-city pro- patients with heterogeneous medical and psychi- gram patients received government assistance, atric diagnoses completed this bilingual MBSR and only 20% were employed. Of the Latinx program, many of whom anecdotally reported Spanish-speaking MBSR participants, 88% had significant personal change, symptom relief, and an annual income below $15,000, as did 72% of improved health (Roth, 1997). To meet the needs English-speaking MBSR participants. Patients of this low-income patient population—78% of either were provider-referred or self-referred to clinic patients received public assistance—the improve coping with stress, pain, illness, anxiety, clinic bills the cost of the MBSR program to and/or depression, and many patients presented patients’ health insurance whenever possible, with a wide variety of medical diagnoses (e.g., uninsured patients pay a sliding scale fee, and no cardiovascular conditions, asthma, cancer, patient is denied MBSR for financial reasons. In chronic fatigue, fibromyalgia, HIV/AIDS) and/or an open design clinical trial (Roth & Creaser, psychiatric diagnoses (e.g., depression, anxiety, 1997), significant improvements on standardized PTSD, insomnia, complicated bereavement, sub- medical and psychological symptom measures, stance abuse recovery). Several accommodations including self-esteem, were documented follow- were made in an attempt to meet the needs of ing MBSR for the 79 study participants who inner-city patients and reduce barriers to access: completed the MBSR program (60% completion (1) Clinic patients attended the MBSR program rate). Given that the majority of patients served free of charge. (2) Onsite childcare was provided by the Community Health Center are Latinx, at no cost. (3) Free transportation was arranged. MBSR was offered in Spanish as well as English. (4) MBSR was offered in both Spanish and Of these 79 study participants, 51 (65%) received English. (5) The timing of classes was scheduled MBSR in Spanish and 28 (35%) in English. A to accommodate specific patient needs, such as chart review examining health-care utilization coordinating morning class times with the local for a subset of Community Health Center school bus schedule to maximize single parent patients who completed MBSR also revealed a attendance or offering evening classes for work- significant decrease in the number of chronic ing MBSR participants. Over the course of care medical visits following MBSR (Roth & 7 years, 538 patients completed the MBSR pro- Stanley, 2002). Thus, MBSR may help reduce gram (65% completion rate), and 452 patients health-care costs by decreasing utilization. In a completed MBSR during their first attempted subsequent non-randomized controlled trial cycle. Significant and comparable improvements (Roth & Robbins, 2004), 48 Spanish-speaking for both English-class and Spanish-class MBSR and 20 English-speaking patients who received groups were found across outcome measures of MBSR were compared to a control group of 18 286 H. Hazlett-Stevens

Spanish-speaking patients who did not receive tial negative connotations by referring to mindful MBSR due to practical constraints. Before inter- stretches and postures as “body movements” vention delivery, the number of medical and (movimientos del cuerpo, in Spanish) or “gentle mental health diagnoses between these two stretches” (estiramientos suaves, in Spanish) groups did not differ, and no differences were instead (Roth & Creaser). For further description found between the Spanish- or English-speaking of culturally sensitive MBSR delivery, see Roth intervention groups beforehand. A total of 68 and Calle-Mesa (2006) for a detailed case study patients completed MBSR (66% completion of a Spanish-speaking Puerto Rican man who rate) and provided complete data for analysis. attended the Community Health Center MBSR The MBSR group reported statistically signifi- program for severe chronic pain, depression, anx- cant improvements on five of eight general iety, and poor self-esteem and subsequently health and social functioning measures when reported profound clinically significant benefits compared to the control group. While prelimi- from the program. Roth and Creaser further sug- nary, results from the Community Health Center gested that other inner-city MBSR programs be studies suggested that MBSR feasibly can be implemented within established health-care cen- delivered in both Spanish and English to diverse ters or agencies already utilized and trusted by inner-city clinic patients in an acceptable and patients in that community. Lastly, agency effective manner. If available, this option might administrators, providers, and staff also must be especially beneficial to Latinx patients suffer- support the MBSR program to ensure successful ing from anxiety disorder symptoms because implementation. MBSR is delivered within the general healthcare setting and is presented as a public health education class. Thus, MBSR can be delivered in Effectiveness of MBIs Among Diverse the very setting Latinx patients are most likely to Populations seek help for anxiety, and the transdiagnostic stress reduction class format may appear less In addition to the establishment of these two US stigmatizing than mental health specialty care. inner-city MBSR programs, a growing research Just as Kabat-Zinn et al. (2016) argued for the effort has examined the effectiveness of various necessity of addressing practical barriers to MBIs among individuals from diverse back- MBSR attendance among inner-city clinic grounds. One meta-analysis examined outcome patients, Roth and Creaser (1997) identified spe- investigations of similar psychotherapies (e.g., cific agency policies needed to maximize MBSR dialectical behavior therapy, DBT) in addition to program access and minimize attrition. Clinics MBSR and MBCT (Fuchs, Lee, Roemer, & are advised to offer MBSR in each patient’s pre- Orsillo, 2013). Only studies that specifically ferred language whenever possible, to address recruited individuals from marginalized back- issues of cost (including the cost of purchasing grounds, including non-White and/or non- devices to listen to meditation recordings), and to European American ethnic or cultural provide childcare, transportation, reminder calls background, older adults, nonheterosexual, low- during the first few weeks, and flexible schedul- income, physically disabled, incarcerated, and/or ing as much as possible. Furthermore, culturally participants whose first language was other than sensitive delivery of MBSR in multicultural the dominant culture, were selected. Three of the inner-city settings requires that MBSR instruc- included investigations in this meta-analysis tors have the flexibility to alter course content were MBI trials conducted with ethnic, racial, or and structure in creative ways that reflect the life cultural minority participants, and one of these experience of participants. For example, Latinx studies was the MBSR trial conducted by Roth patients may find the mindfulness meditation and and Robbins (2004) described above (Hedges’ g movement practices quite strange at first, yet effect size of 0.67). In another of these studies instructors can avoid the word yoga and its poten- (Garland, Gaylord, Boettiger, & Howard, 2010), 20 Cultural Considerations When Treating Anxiety Disorders with Mindfulness-Based Interventions 287 participants were recruited from an urban US groups were included in at least one study with community, resulting in a clinical sample of pre- the exception of Native Alaskans. MBSR was the dominantly male (79%), African American most common MBI studied (29%), and the (60%), and low-income (almost 53% earned less MBCT for children study described above than $20,000 annually) alcohol-dependent adults. (Semple et al., 2010) was the only MBCT study The MBCT protocol adapted for alcohol depen- identified. Other MBI protocols targeted condi- dence outperformed a support group control tions such substance abuse or pregnancy or were intervention (Hedges’ g = 0.43) in this random- developed to promote health and well-being ized trial. The final study identified by Fuchs among children in schools. Only one investiga- et al. (Semple, Lee, Rosa, & Miller, 2010) ran- tion compared intervention effectiveness across domized 25 children, mostly from low-income, ethnoracial groups (Witkiewitz, Greenfield, & inner-city households, to MBCT adapted for chil- Bowen, 2013). In this last investigation, racial dren or to a wait-list control group. Of the 25 and ethnic minority women enrolled in a residen- children participating, 15 identified as Latinx, 6 tial addiction treatment program and randomized as African American, and 4 as Caucasian. to MBRP reported no drug use days and lower Participants who completed the MBCT program addiction severity at 15-week follow-up when showed greater improvements in attention prob- compared to a standard relapse prevention group. lems compared to the control group, both imme- Regression analyses revealed that the benefit of diately post-intervention (Hedges’ g = 0.43) and MBRP over standard relapse prevention was at 3-month follow-up. Children with clinically more pronounced for racial and ethnic minority elevated anxiety before MBCT also demonstrated participants versus non-Hispanic White partici- significant reductions in anxiety symptoms and pants. Witkiewitz et al. proposed that the highly behavior problems following the intervention. individualized and experiential nature of MBSR More recently, DeLuca et al. (2018) conducted might have increased its cultural relevance for a systematic review of MBI studies conducted racial and ethnic minority participants, whereas with ethnoracial minority representation or the standard relapse prevention program examining cultural adaptations of MBIs. They employed a more didactic format to teach univer- identified 24 investigations in which at least 75% sal coping strategies. of the sample included ethnoracial minority individuals, the investigation tested a culturally adapted MBI, or the effectiveness of the MBI was Cultural Adaptations of MBIs compared between different ethnoracial groups. Of the 24 studies meeting at least one of these Each of the MBI research investigations described selection criteria, 11 used single-sample open thus far delivered an MBI originally tested with trial designs and 13 were randomized controlled predominantly White participant samples (e.g., trials. Of the 13 randomized trials, seven evalu- MBSR, MBCT, MBRP). When subsequently ated the effects of MBIs on health or mental delivered to diverse individuals, these protocols health conditions, although none of these studies often were modified to overcome practical barri- required a specific diagnosis for inclusion. The ers to access, such as reducing session length or remaining six randomized trials studied children providing the MBI in an alternative language. or youth samples in the absence of diagnostic Additionally, investigators aimed to deliver the inclusion criteria. Cohen’s d effect sizes across MBI in culturally sensitive ways to improve dependent measures varied greatly, ranging from acceptability while maintaining the core curricu- 0.10 to 0.62 for single-sample studies and from lum of the MBI. In contrast, another approach to 0.02 to 0.99 for randomized trials. Hispanic/ culturally sensitive MBI delivery involves creat- Latinx and African American individuals were ing an entirely new culturally adapted interven- most represented in this research literature, tion developed from within the specific culture of although all major US ethnoracial minority interest. Proulx et al. (2018) argued for this 288 H. Hazlett-Stevens

alternative approach out of concern that well- population. One cited example described how intentioned mindfulness instructors may engage mindfulness meditation could be adapted for a cultural minority participants in unrecognized community of African American adults to be biased ways, thereby preventing these partici- compatible with biblical principles: Woods- pants from fully engaging the mindfulness pro- Giscombé and Gaylord (2014) noted similarities gram. Subtle MBI instructor behaviors involving between the cultural practice of prayer to try “to how participants are addressed, instructor use of listen to what God is telling you” and the empha- language, and/or the selection of teaching meta- sis on stillness and present-moment awareness in phors or stories described, although uninten- mindfulness meditation. Another example involv- tional, could appear unsupportive of participants’ ing Native American communities incorporated cultural framework. Without awareness, MBI material from native storytellers to convey how instructors might convey that they are encourag- mindfulness could be practiced as a means of ing American minority communities to become developing careful attention (Le & Gobert, 2015). more like White American communities and In a final example, a culturally adapted mindful- therefore are not interested in how spiritual tradi- ness intervention for mixed ethnic Native tions within the culture resonate with mindful- Hawaiian/Pacific Islander incarcerated youth ness instructions. Proulx et al. also observed that incorporated symbolic and spiritual meanings of minority community members often experience the words aloha and mahalo throughout the an additional burden of having to reinterpret mindfulness curriculum (Le & Proulx, 2015). intervention material into their own cultural From this CBPR perspective, a member from framework, ironically placing an extra layer of within a given minority community should play a stress onto their stress reduction class attendance. leadership role in developing the MBI from Proulx et al. therefore proposed that MBI within that cultural context whenever possible researchers adopt a community-based participa- (Proulx et al.). tory research (CBPR) approach in which researchers first engage the community of interest to learn about future participants’ cultural Summary and Conclusions perspectives beforehand, ensuring a more culturally responsive MBI research program. Individuals from minority cultures often experi- Proulx et al. (2018) emphasized the impor- ence increased psychosocial stress resulting from tance of MBI researchers engaging the American discrimination and microaggressions, and inner- minority community of interest by reaching out city communities are challenged by the stress of to leaders within that community first. poverty—MBIs targeting stress reactivity there- Researchers must be careful to build trust with fore might be especially beneficial to diverse community leaders and members as they seek to communities for these reasons (Kabat-Zinn et al., understand the community’s particular concerns, 2016; Proulx et al., 2018). However, the docu- needs, and perspectives and convey a genuine mented mental health-care disparities found with intention to develop a mindfulness intervention other evidence-based interventions appear pro- that identifies and enhances cultural strengths. nounced for MBIs, possibly in part due to their For example, researchers engaging African Buddhist origins. MBIs might offer an optimal American communities must acknowledge intervention approach for minority individuals America’s long history in which physicians seeking to alleviate clinical anxiety because: (1) knowingly harmed African Americans, creating MBSR is delivered within the medical setting profound mistrust of medical establishments. context where many patients first seek help for Proulx et al. further argued that researchers must anxiety, (2) MBSR involves a health education remain open to each community’s particular cul- class format that avoids the stigma of mental tural perspectives and be willing to fit their inter- health specialty care, and (3) various MBIs have vention approach to the culture of that specific demonstrated effectiveness to reduce clinical 20 Cultural Considerations When Treating Anxiety Disorders with Mindfulness-Based Interventions 289 anxiety disorder symptoms. Unfortunately, Azocar, F., Areán, P., Miranda, J., & Muñoz, R. F. (2001). Differential item functioning in a Spanish translation research to date has not examined the efficacy of of the Beck depression inventory. Journal of Clinical MBIs specifically for anxiety disorders among Psychology, 57(3), 355–365. https://doi.org/10.1002/ diverse populations. MBSR does appear to be an jclp.1017 acceptable and effective intervention when deliv- Barrios, V., Blackmore, M., & Chavira, D. (2016). Using integrated care to treat anxiety among Latino popu- ered within culturally diverse and low-income lations. In L. T. Benuto & W. O’Donohue (Eds.), US communities (e.g., Kabat-Zinn et al., 2016; Enhancing behavioral health in Latino populations Roth & Robbins, 2004), and other MBIs show (pp. 187–205). Basel, Switzerland: Springer. promise when delivered to diverse populations as Berkel, C., Knight, G. P., Zeiders, K. H., Tein, J. Y., Roosa, M. W., Gonzales, N. A., & Saenz, D. well (DeLuca et al., 2018). Nevertheless, much (2010). 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Elisabeth Cordell and Robert Holaway

Introduction medical texts (Pitman, 1994; Reynolds & Kinnier Wilson, 2012). The Babylonians were known to Obsessive-compulsive disorder (OCD) is a com- be remarkable chroniclers of disease and behav- mon and chronic neuropsychiatric disorder which ior, and they described obsessional themes of con- is estimated to be the tenth leading cause of dis- tamination, aggression, orderliness of objects, ability in the world (Murray & Lopez, 1996; sex, and religion, with obsessions often accompa- Pittenger, Kelmendi, Bloch, Krystal, & Coric, nied by objective behavioral habits that were 2005). OCD is characterized by the presence of “unbreakable” (Reynolds & Kinnier Wilson, obsessions and compulsions. Obsessions are 2012). These descriptions map onto our modern- recurrent, intrusive, persistent thoughts, impulses, day understanding of OCD symptom dimensions urges, or images that are experienced by an indi- with surprising accuracy. vidual as unwanted, whereas compulsions are rit- Despite historical accounts of OCD from ualistic, repetitive, stereotyped behaviors or ancient cultures, the multifaceted construct of mental acts (American Psychiatric Association, cultural identity and its impact on the clinical 2013). Individuals with OCD often experience manifestation of OCD has been largely under- marked anxiety as a result of the distressing studied. Although limited, existing literature does obsessional thoughts and feel a strong drive or suggest that cultural factors have an impact on an unrelenting urge to perform repetitive acts (com- individual’s understanding of their symptoms, pulsions) to neutralize or reduce the anxiety treatment-seeking behaviors, type of symptoms caused by the intrusive thoughts (obsessions). experienced, and severity of symptoms These time-consuming and anxiety-provoking (Fontenelle, Mendlowicz, Marques, & Versiani, symptoms can cause significant functional impair- 2004; Medeiros et al., 2017; Yorulmaz & Isik, ment and interference with individual’s activities 2011; Zohar, Goldman, Calamary, & Mashiah, of daily living (Pittenger et al., 2005). 2005). As we strive to be culturally competent Descriptions of obsessive-compulsive behav- practitioners equipped to integrate cultural iden- ior can be traced as far back as the seventh century tity in the delivery of best-practice treatment for AD, with one of the most compelling depictions diverse clients, it has become increasingly impor- coming from seventeenth-century Babylonian tant to understand the extent and the mechanisms through which cultural forces shape OCD. This chapter presents an overview of the ways E. Cordell · R. Holaway (*) in which the culture of an individual impacts the PGSP-Stanford Psy.D. Consortium, Palo Alto presentation and course of OCD. After reviewing University, Palo Alto, CA, USA

© Springer Nature Switzerland AG 2020 293 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_21 294 E. Cordell and R. Holaway the cross-cultural prevalence of OCD, we high- Many studies have conducted more granular light practical implications for assessment of investigations of the ECA program data by exam- OCD and examine how individual diversity fac- ining rates of OCD among smaller subpopulations tors influence OCD phenomenology and severity, within the USA, and these findings have yielded with a special focus on the role of religion, cul- consistent results (Breslau et al., 2006; Karno turally defined superstitions, and race. et al., 1988, 1989). In fact, OCD prevalence rates have demonstrated more stability and consistency among culturally diverse subsets than other anxi- Prevalence of OCD Across the USA ety disorders. In one of the most interesting find- and Abroad ings, researchers investigated prevalence rates of psychiatric disorders among US-born Mexican- Prior to the 1980s, not much was known about Americans, immigrant Mexican-Americans, and the prevalence of OCD in the US general popula- native non-Hispanic Whites. Rates of many anxi- tion, much less across the globe (Rasmussen & ety disorders—including simple phobia, agora- Eisen, 1990). However, the epidemiology of psy- phobia, and generalized anxiety disorder—varied chiatric disorders became an area of intense among these three distinct groups. However, simi- research interest in the late 1990s and early 2000s lar variance in lifetime prevalence rates associated as diagnostic criteria achieved greater reliability, with ethnic and nation-of-origin differences was and interest in the public health significance of not found for OCD (Breslau et al., 2006; Karno psychiatric disorders grew. As a result of these et al., 1988, 1989). intensified research efforts, the prevalence rates Looking beyond the USA, the prevalence of OCD are now known to demonstrate remark- rates of OCD display replicability cross- able consistency across culturally diverse popula- culturally. The 2000 British National Psychiatric tions within the USA and around the globe. Morbidity Survey, consisting of 8580 individu- It was once believed that the prevalence of als, reported a similar lifetime prevalence rate of OCD in the general US population was only 1.1% (Torres et al., 2006). While this is a useful 0.05% (Rasmussen & Eisen, 1990). However, finding, its cross-cultural significance is limited the National Comorbidity Survey Replication by the similarity between US and UK culture. (NCS-R), a face-to-face household survey con- However, a study of seven countries (Canada, ducted with 9282 English-speaking respondents Puerto Rico, Germany, Taiwan, South Korea, living in the USA between February 2001 and New Zealand, and the USA) did find consistent April 2003, found that 1.6% of the US popula- lifetime and annual prevalence rates across these tion met criteria for OCD within their lifetime culturally distinct regions (Weissman et al., and 1% of the population met criteria for OCD 1994). For example, the OCD annual prevalence within the last year (Kessler, Chiu, Demler, & rates ranged from 1.1% in South Korea and New Walters, 2005; Kessler et al., 2005; Ruscio, Zealand to 1.8% in Puerto Rico. Taiwan was an Stein, Chiu, & Kessler, 2010). These NCS-R exception, with a rate of 0.4%; however, it is findings corroborated estimates from earlier worth noting that Taiwan had the lowest preva- US-focused research efforts. For example, the lence rates for all psychiatric disorders. This may Epidemiologic Catchment Area (ECA) program be accounted for by culturally influenced under measured the prevalence of OCD in five US reporting of psychiatric illness due to stigma, communities and found the lifetime rates to poor understanding of mental health, or a unique range from 1.9% to 3.3% (Karno, Golding, conceptualization of symptoms. For example, Sorenson, & Burnam, 1988). Thus, discovering some evidence suggests that Asian cultures that OCD actually occurred 50–100 times more exhibit more reluctance when it comes to disclos- frequently than previously estimated was a mon- ing psychological symptoms and an increased umental research finding. likelihood of keeping problems within the family 21 Obsessive-Compulsive and Related Disorders 295 system (Cheung, 1991; Nedeljkovic, Moulding, seeking, as well as response to treatment (Jorm Foroughi, Kyrios, & Doron, 2012). et al., 1997; ten Have et al., 2010). For example, Although the occurrence of OCD appears to in Western cultures, OCD is viewed as a disor- be remarkably consistent cross-culturally, this der caused largely by biological factors, rather conclusion is limited by the fact that much of the than cultural constructs (Coles & Coleman, epidemiological findings to date are from popula- 2010). Interestingly, survey data assessing mentions in the USA, Western Europe, and other tal health literacy for anxiety disorders, OCD, global, industrialized nations. In fact, a review and depression collected from undergraduate conducted by Fontenelle, Mendlowicz, and psychology students enrolled in a public univer- Versiani (2006) found greater variability in the sity in the USA showed that respondents were epidemiology of OCD than has been reported in able to recognize symptoms of OCD with other studies. However, this variance may be greater frequency than other anxiety disorders accounted for by different diagnostic instruments (i.e., panic disorder and generalized anxiety dis- used among the studies in the review. To fully order; Coles & Coleman, 2010). Not only were understand the prevalence of OCD across ethni- students able to identify OCD symptoms, 50% cally and culturally diverse populations, more of respondents attributed these symptoms to research is needed in regions other than North mental illness, a number that is promisingly America and Western Europe, where greater vari- high, but also surprisingly low for a sample of ability in cultures exists. students pursuing higher education with an interest in psychology. This combined identification and attribution of symptoms led most Implications for Assessment (roughly four out of five) students to recom- and Treatment mend seeking help with a professional for OCD symptoms. Help-Seeking Behaviors Relatively similar data from a culturally diverse sample shows comparable findings. A A number of interrelated factors are associated study by Picco et al. (2016) investigated mental with the likelihood that a client makes it into the health literacy in a large sample of Singapore office of a mental health professional for treat- residents. Their study solicited beliefs about help ment. A primary factor, known to be a barrier to seeking, treatment options, and expected out- treatment seeking and one which has been shown comes for OCD and other mental disorders to be culture-context dependent, is mental health (Picco et al., 2016). They found that “see a doctor literacy. Extending beyond just a basic under- or general practitioner” was recommended most standing of one’s symptoms, mental health liter- frequently (26.8%) as the best source of help for acy refers to the “knowledge and beliefs about a fictional vignette depiction of an individual mental disorders which aid their recognition, with OCD. Though individuals associated OCD management, or prevention” (Jorm et al., 1997). with a need to seek professional help instead of Thus, mental health literacy concerns individu- “talk to family or friends,” this far outpaced the als’ beliefs about help seeking, understanding of choices “see a psychologist” (9.8%) and “see a treatment options, and expected outcomes. counselor” (6.6%) and also marginally outper- Broadly speaking, European and Northern formed “see a psychiatrist” (26%). These find- American cultures tend to exhibit greater under- ings suggest that poor understanding of the types standing and more positive beliefs about mental of treatments offered by mental health profes- disorders when compared to Asian and African sionals likely influences one’s perception of help- cultures (Altweck, Marshall, Ferenczi, & seeking options. Lefringhausen, 2015). This increased fund of Lack of clarity around professional care and knowledge about mental illness in turn has been poor perceived effectiveness of the mental shown to positively impact patterns of help health profession were also found in a study 296 E. Cordell and R. Holaway investigating attitudes toward mental health culturally—ranging from 38% in Australia to seeking in Europe. In fact, one-third of respon- nearly 100% in Italy, Japan, and Spain (Kirmayer dents reported the belief that professional care et al., 2012; Nicolini, Salin-Pascual, Cabrera, & was worse than or equal to no help when faced Lanzagorta, 2017). with serious emotional difficulties (ten Have Culture not only influences the symptoms that et al., 2010). people experience, as we will discuss later in this The type of obsessions a person experiences chapter, but perhaps more importantly the symp- can also impact treatment-seeking behaviors toms that they report, how they make sense of (e.g., delayed treatment seeking, hesitance to dis- their symptoms, whether they seek help, where cuss specific content of obsessions, complete they go to seek help, and the extent to which avoidance of treatment). Individuals with OCD stigma is attached to their help-seeking behaviors who experience more “taboo” obsessions often (General (US), Services (US), & Health (US), delay seeking help. A group of researchers who 2001). As providers, globally, we are tasked with investigated the clinical features of OCD in a the challenge of clarifying the perceived value of sample of 141 Turkish patients who had been helping professions and demystifying the role admitted to an outpatient clinic found that indi- mental health providers play in the treatment of viduals with sexual obsessions and religious mental illness. obsessions had delayed seeking professional help (Karadag, Oguzhanoglu, Ozdel, Ateşci, & Amuk, 2006). Though it is well established that patients Culturally Adapted Assessment with OCD in general often delay treatment seek- Measures ing due to the shame associated with their symptoms, the authors highlighted the role of cultural The first step in identifying OCD symptoms norms in Turkey and how they may have contrib- requires conducting a thorough, evidence-based uted, in part, to this delay. For example, in assessment. The Yale-Brown Obsessive- Turkey—as is the case in most Middle Eastern Compulsive Scale (Y-BOCS) is the gold- countries—topics of sex and religion are socially standard, clinician-administered assessment used taboo, and the authors speculate that this may be to measure the severity of OCD symptoms exacerbating the delay in help seeking among (Goodman et al., 1989a, 1989b; Goodman & patients with more “taboo” obsessional content. Price, 1992). Similarly, a study of Egyptian patients also The Y-BOCS contains two main components. showed that the role of culture mediated patients’ The first is a 54-item symptom checklist, which attitudes toward help seeking and in some cases contains commonly reported obsessions and resulted in a delay in approaching treatment compulsions, grouped together by themes in (Okasha, Saad, Khalil, El Dawla, & Yehia, 1994). content (i.e., aggressive obsessions, contamina- Data suggest that this delay is not negligible, as tion obsessions, religious obsessions, sexual the average delay in professional help seeking in obsessions, cleaning/washing compulsions, a sample of 135 OCD patients in Iran was checking compulsions, etc.). In addition to the 8.7 years (Ghassemzadeh et al., 2002). symptom checklist, the Y-BOCS includes a ten- Similarly related to help-seeking behavior item severity measure—with five questions that among individuals with OCD, the acceptability ask about obsessions and five questions that of pharmacological treatments for OCD can be solicit information on compulsions. Each of influenced by an individual’s beliefs about medi- these ten items measures five distinct dimen- cal and psychiatric treatments, as some patients sions, time/frequency, amount of interference, are more willing than others to try pharmacologi- subjective distress, internal resistance, and cal interventions as an adjunct to—or instead degree of control, and is rated on a scale from 0 of—psychotherapy. As a result, the use of medi- (none) to 4 (extreme). This enables the assessor cation for OCD varies significantly cross- to calculate a separate severity score for both 21 Obsessive-Compulsive and Related Disorders 297 obsessions and compulsions. Each of these sepa- ized behaviors. Thus, ERP asks a patient to face rate ratings can then be added together for a total their obsessions and/or feared situations while score that can range from 0 to 40. In addition to refraining from any behavior designed to neutral- the clinician-administered version, there is a ize or attenuate the associated anxiety that they self-report version of the Y-BOCS (Steketee, experience. It is well established that access to Frost, & Bogart, 1996). gold-standard behavioral therapy for OCD is lim- Cross-cultural validity of the Y-BOCS is good, ited within the USA, as there are few clinicians and many of the psychometric properties stand trained in ERP, especially outside of major met- up across international cohorts of psychiatric ropolitan areas, and most charge high rates and inpatients and outpatient populations (Arrindell, do not accept insurance. Unfortunately, there is a de Vlaming, Eisenhardt, van Berkum, & Kwee, paucity of research that has examined access to 2002; Asadi et al., 2016). To date, the Y-BOCS ERP and other evidence-based treatments for has been translated and psychometrically vali- OCD outside of the USA. dated into numerous languages, including Despite the strong evidence base of ERP as Chinese, Spanish, French, Italian, German, the first-line behavioral treatment for OCD, very Portuguese, Arabic, Persian, Hungarian, Iranian, little research has examined the integration of Thai, Dutch, and several additional languages cultural factors into existing evidence-based (Arrindell et al., 2002; Asadi et al., 2016; treatments for the disorder. However, some Esfahani, Motaghipour, Kamkari, Zahiredin, & research has explored ways to adapt ERP for Janbozorgi, 2012; Harsanyi et al., 2009; individuals with specific subtypes of OCD, like Hiranyatheb, Saipanish, & Lotrakul, 2014; religious or scrupulosity OCD. ERP for this type Jacobsen, Kloss, Fricke, Hand, & Moritz, 2003; of OCD is often poorly tolerated, as the nature of Melli et al., 2015). A Persian version of the treatment asks the patient to act in discord with Y-BOCS evaluated on a sample of 170 partici- their underlying moral code. pants reports excellent internal consistency Huppert, Siev, and Kushner (2007) published (Cronbach’s alpha of 0.97 for the symptom a study of culturally adapted ERP for orthodox checklist and 0.95 for the severity scale, Esfahani Jews. Their findings found that treatment efficacy et al., 2012), and the Portuguese adaptation of the was contingent on clinicians providing a strong scale reports similarly compelling internal con- rationale for ERP and clients having an enhanced sistency and test-retest reliability scores (Castro- motivation to participate in therapy. In addition, Rodrigues et al., 2018). Additional measures of they found that it was crucial for clinicians to obsessive-compulsive disorder exist, many of incorporate a client’s religious values into this which also have culturally adapted versions. (For process (Huppert et al., 2007). For example, the a comprehensive review of evidence-based authors noted that by highlighting the extent to assessment measures and methodologies for which OCD is a barrier to the spiritual connec- OCD, see Nakagawa, Marks, Takei, De Araujo, tion one wishes to have with God, a clinician & Ito, 1996; Rapp, Bergman, Piacentini, & could significantly increase one’s motivation to McGuire, 2016.) engage in ERP and confront their obsessions and compulsions associated with OCD. In addition, the authors emphasized the importance of distin- Treatment Considerations guishing between rituals that are required by religious law and those that are part of OCD The gold-standard behavioral treatment of choice symptomatology. This can be particularly diffi- for OCD is exposure and response prevention cult for the therapist that is unfamiliar with ortho- (ERP)—a type of cognitive behavioral therapy dox communities, as both rituals can be precise, (CBT) that exposes individuals to their obses- time-consuming, and repetitive in nature. As a sions and associated anxiety while also resisting result, clinicians may benefit from incorporating the urge to perform a compulsion or other ritual- a religious authority or counselor, such as a rabbi, 298 E. Cordell and R. Holaway when treating an Orthodox Jew or other clients sexuality, and patients who experience this type whose religious views intersect with their OCD. of OCD struggle with tolerating the uncertainty Closely related to OCD that involves religious that they may not be the sexual orientation that themes, scrupulosity is a type of OCD in which aligns most closely with their identity. individuals’ obsessions focus on religious or It’s important to note that when individuals moral fears, such as sin, divine retribution, and the exhibit H-OCD, they are often times worried that implications of being an evil or bad person their ability to have a relationship with a member (Ciarrocchi, 1995; Purdon & Clark, 2005). of the sex they are most attracted to will be com- Scrupulosity can appear phenomenologically promised. For example, a heterosexual male who similar to other OCD subtypes (e.g., an individual is married to a woman may fear that he will lose who repeats a religious requirement to be certain or have to leave his wife and children in order to that she or he performed it properly), but the ulti- live as his “authentic self” (i.e., gay male). mate feared consequence is religious or moral in Individuals who suffer with H-OCD become nature. Although usually related to religious hypervigilant to signs that they are experiencing observance or beliefs, scrupulosity can also mani- some attraction toward a member of the same sex fest in extreme forms of moral behavior in a non- (or opposite sex if the individual is lesbian or religious context, and nonreligious individuals gay) and begin to scan their body looking for can also be affected by these concerns. As noted signs of excitement and arousal. They often seek above, it is important for treating clinicians to reassurance from their desired partners, which— familiarize themselves with a client’s religious in turn—can compromise the loving relationship views and practices and to consult with clergy or they are trying desperately to protect, and they other knowledgeable individuals when necessary. can begin to misinterpret friendly glances or The literature for culturally competent treat- exchanges with passersby as evidence that they ment of OCD is surprisingly lacking. Much more were intentionally checking out a member of the remains to be uncovered in this domain—namely same sex. cross-cultural treatment preferences and out- Sexual orientation obsessions fall within the comes. Ultimately, it is the job of the clinician to larger category of sexual obsessions but have incorporate evidence-based research, clinical been studied less frequently than other common judgment, and the patient’s values to determine OCD subtypes. Factor analyses show that sexual the appropriate treatment approach for each indi- orientation obsessions, and sexual obsessions in vidual client. general, load onto a “taboo and unacceptable thoughts” factor, which is clinically important as these types of obsessions often result in increased Culturally Competent Treatment shame and delayed treatment seeking (Pinto of Individuals with Homosexuality et al., 2007). Obsessions A culturally competent therapist with limited knowledge of OCD subtypes may view the best One particular form of OCD, known as homo- intervention for a client with H-OCD to be one sexuality OCD (H-OCD) and sometimes referred that is LGBTQ affirmative and acceptance based. to as sexual orientation OCD (SO-OCD), occurs Though this would be the most culturally compe- when an individual—straight or gay—obses- tent approach if the patient was indeed struggling sively questions or doubts their sexuality. Despite with their sexuality and looking for support with the H-OCD moniker, this subtype of obsessional coming out as gay, lesbian, bisexual, or transgen- symptoms can occur to both heterosexual indi- der, such an approach would fail to confront the viduals who are questioning whether they might patient’s worst fear and would not help the patient be gay and lesbian/gay individuals who are ques- to tolerate uncertainty, both of which are two tioning whether they might actually be straight. common pitfalls of exposure and response pre- In both cases, the obsessional focus is on one’s vention treatment for OCD (Gillihan, Williams, 21 Obsessive-Compulsive and Related Disorders 299

Malcoun, Yadin, & Foa, 2012). The wrong epidemiological data may suggest (Nedeljkovic approach to treatment can be harmful at best and et al., 2012). detrimental at worst. Williams (2008) describes a Culture seems to exert its most salient influ- case with H-OCD where the therapist chose to ence on the manifestation or presentation—not make the patient’s sexual activity the focus of the prevalence—of OCD symptoms. Earlier in therapy, rather than ERP, resulting in a worsening this chapter, we reviewed the epidemiological of symptom severity and an increase in suicidal data suggesting the occurrence of OCD is not ideation. restricted to a particular culture or geographical The best treatment of choice for H-OCD con- region. However, although individual cultural tinues to be ERP. A case report of a 51-year-old, factors may not play a role in the prevalence or white, heterosexual male with H-OCD showed existence of OCD, culture does appear to influ- that 17, twice-weekly sessions of ERP showed ence the type or presentation of OCD symptoms. monumental symptom reduction as measured by Specifically, individual cultural factors seem to the YBOCS, along with meaningful improve- influence the specific themes of obsessions that ments in the patient’s mood, quality of life, and are experienced by individuals with OCD. social adjustment (Williams, Crozier, & Powers, Considerable evidence suggests that most 2011). These outcomes are particularly impres- people, not just OCD patients, have experienced sive considering that a previous pharmacotherapy intrusive or unwanted thoughts. A study pub- intervention had failed to result in meaningful lished by Radomsky and colleagues investigated symptom change for this case. the universality of unwanted intrusive thoughts As research surrounding culturally competent by assessing 777 nonclinical individuals from 13 treatment of LGBTQ populations expands, many countries across 6 continents (Radomsky et al., specialty clinics have been created to serve indi- 2014). They found that the majority of individu- viduals questioning their sexual orientation, gen- als in all countries (93.6%) reported experiencing der identity, or other preferences related to the intrusive thoughts at least once in the last intersection of their sex, gender, and identity. 3 months. These findings built upon the seminal These clinics are a fantastic resource that speak research of Rachman and de Silva that suggests to the ability of behavioral health specialists to clinical, obsessional symptoms develop not due adapt to the culturally defined needs of an evolv- to an abnormal phenomenon, but rather as a result ing patient population. However such a treatment of reacting to or misinterpreting a consistently facility may not be the appropriate treatment normal experience of having an intrusive thought direction for an individual with H-OCD, pro- (Rachman, 1997; Rachman & de Silva, 1978). vided that they do not offer ERP. Whereas sexual Now consider for a moment the likelihood of orientation obsessions may seem unique in their misinterpreting an intrusive thought. Are indi- own respect, they are in fact a common symptom viduals more likely to react to an intrusive subtype of OCD that responds well to the first- thought that is completely random and arbitrary, line, gold-standard behavioral treatments. or one that concerns something they care about deeply? Obsessions encompassing themes from major moral systems or regarding a person, Individual Diversity Factors object, or belief that matters deeply to an indi- and OCD Symptom Onset, vidual are more likely to be distressing and there- Presentation, and Severity fore more likely to be interpreted as significant or threatening. In short, intrusive thoughts about Given the remarkable consistency in the preva- things that matter make the thoughts more lence of OCD cross-culturally, one could “sticky”—lending themselves to easily being assume that OCD may be immune to cultural misinterpreted and in turn becoming obsessional influence; however, the role of culture in OCD content. Thus, given that cultural constructs often symptomatology is more nuanced than clinical dictate the things that matter, culture can in turn 300 E. Cordell and R. Holaway have a significant influence on the content of inability to dismiss the distressing intrusive obsessions. thought contribute to an overreaction or misat- tribution of the significance of the thought and, as a result, increase the probability that the The Role of Religion thought will become a persistent and recurrent obsession. Religion is one cultural factor that is considered important in the presentation of OCD. Consider for a moment the belief systems and behaviors Culturally Defined Superstitions that are influenced by one’s religion. Religion can be a strong force in one’s life, significantly Thought-action fusion (TAF) is a cognitive bias influencing an individual’s values, morals, that is somewhat unique to OCD. It is a form of beliefs, and concerns. Individuals with strict reli- superstitious, magical thinking that links unre- gious beliefs may be more prone to developing lated events or actions. There are two main types clinically relevant obsessions as a result of attach- of TAF: (1) moral TAF, which is the belief that ing a high significance or attributing a meaning- having unacceptable or blasphemous thoughts ful level of threat to unwanted intrusive thoughts are as bad as actually carrying out the action dic- that go against the beliefs defined by their faith tated by the thought (i.e., the thought of killing (de Silva, 2006; Steketee, Quay, & White, 1991). my newborn infant is as bad as actually murder- In fact, Steketee et al. (1991) found that, whereas ing the newborn), and (2) likelihood TAF, the individuals with OCD were not more religious belief that having an unacceptable or disturbing than other anxious individuals, participants with thought will increase the likelihood that the OCD who were more religious were more likely thought will occur in reality (i.e., the belief that to report religious obsessions but not sexual or thinking the plane might crash will cause the aggressive ones. plane to crash; Amir, Freshman, Ramsey, Neary, Religion plays a role in the phenomenology of & Brigidi, 2001; Lee, Cougle, & Telch, 2005; OCD, and the literature demonstrates that higher Shafran, Thordarson, & Rachman, 1996). religiosity is associated with increased obsessive- Thought action fusion is, at its core, a supersti- compulsive traits (Koenig, Ford, George, Blazer, tion that takes on power through the extent to & Meador, 1993; Nicolini et al., 2017). For which it violates our moral codes. It is also a key example, Sica, Novara, and Sanavio (2002) cognition that is specific to OCD and is important investigated OCD symptoms and cognitions in to address in the context of OCD treatment. TAF three groups in Italy: 54 Catholic nuns and friars, intersects with culture in a meaningful way, as 47 lay Catholic persons who regularly attended nearly all superstitions are culturally defined, and church, and 64 students not particularly involved some cultures are more superstitious than others. with religion. The two religious groups scored For example, Yorulmaz and Isik (2011) investi- higher than the low-religiosity students on mea- gated TAF and OCD symptoms among three cul- sures of obsessionality, over-importance of turally distinct samples and found that culture thoughts, and control of thoughts (de Silva, 2006; impacted TAF beliefs and other thought control Sica et al., 2002). strategies (Yorulmaz & Isik, 2011). Thus, individuals with strict religious back- Behavioral treatment of OCD that is associ- grounds may be less able to dismiss an unwanted ated with TAF beliefs can be quite difficult to intrusive thought—especially one that is blas- complete, as there may be little willingness to phemous or sexual in nature—because these view one’s TAF beliefs as OCD instead of thoughts are very likely to be interpreted by the common, culturally sanctioned views, ulti- religious individual as particularly bad, sinful, or mately interfering in a client’s engagement in immoral. That overvaluation, judgment, and treatment. 21 Obsessive-Compulsive and Related Disorders 301

Obsessive-Compulsive Spectrum to the dearth of literature investigating the Disorders influence of culture on OCSDs. Table 21.1 outlines the relevant—yet still restricted— With the advent of DSM-5, a new classification nascent literature on culturally competent of disorders was created, known as the obsessive- assessment and treatment of body dysmorphic compulsive spectrum disorders (OCSDs). OCD disorder, excoriation disorder, and hair-pull- is the hallmark of this relatively new diagnostic ing disorder. category; however, body dysmorphic disorder Obsessive-compulsive spectrum disorders (BDD), hair-pulling disorder, hoarding disorder, (OCSDs) include diagnoses such as body dys- and excoriation (i.e., skin picking) disorder are morphic disorder, excoriation (skin-picking) dis- the obsessive-compulsive related disorders that order, and trichotillomania (hair-pulling) also reside in this new category. While this is a disorder. The literature examining culturally heterogeneous group of diagnoses, these disor- informed assessment and treatment of these dis- ders have common features including repetitive, orders is considerably limited, but this table high- intrusive thoughts, distressing emotions, and lights early research that has been conducted compulsive or repetitive behaviors. examining the role of culture in assessing and The relatively limited body of research on treating these disorders and provides relevant OCD and culture is expansive when compared citations.

Table 21.1 Literature supporting culturally informed approaches to assessing and treating obsessive-compulsive spectrum disorders Diagnosis Assessment Treatment Body dysmorphic A culturally adapted Brazilian Portuguese Two case examples of culturally adapted disorder version of the Y-BOCS scale modified for cognitive behavioral treatment strategies for body dysmorphic disorder (BDD-YBOCS) BDD were published by Weingarden et al. was translated and validated by de Brito (2011). The cases highlight how clinicians can et al. (2015) integrate cultural variables into an interventional framework for a 40-year-old, married, Jewish male and a single, 30-year-old African-American male with BDD Excoriation The Skin Picking Scale-Revised has been The authors are not aware of any publications (skin-picking) translated and validated into German concerning culturally competent treatment of disorder (Gallinat, Keuthen, & Backenstrass, 2016) excoriation or skin-picking disorder Leibovici and colleagues conducted a culturally informed survey of skin-picking disorder among Israeli Jewish and Arab communities to determine prevalence rates and demographic correlates of the disorder (Leibovici et al., 2015) Keuthen and colleagues have conducted an analysis of the differences between Israeli adults with clinical and subclinical skin- picking characteristics (Keuthen et al., 2016) Hair-pulling Several forms of assessing trichotillomania Falkenstein and colleagues have published a disorder (TTM) exist. Due to the nature of the randomized controlled trial evaluating (trichotillomania) disorder, a multimodal assessment is often treatment outcomes for trichotillomania among recommended. For a thorough review of non-Hispanic White and racial/ethnic minority assessment techniques, see “Diagnosis, participants (Falkenstein, Rogers, Malloy, & Evaluation, and Management of Haaga, 2015) Trichotillomania” (Woods & Houghton, Neal-Barnett et al. (2010) have also contributed 2014) to the intersecting literature of ethnic identity and hair-pulling disorder phenomenology, impairment, and treatment outcomes 302 E. Cordell and R. Holaway

Cross-Cultural Similarities: A Case countries. The four OCD factors they identified for a Biological Model of OCD were: (1) a symmetry factor, which contained symmetry obsessions and ordering, repeating, In addition to influencing an individual’s beliefs and counting compulsions, (2) forbidden thoughts about symptomatology and motivating treatment- factor, which contained aggressive, sexual, and seeking behaviors, cultural factors can have a religious obsessions, (3) cleaning factor, which meaningful impact on the content of obsessions contained contamination obsessions and cleaning in OCD (Fontenelle et al., 2004). However, given compulsions, and (4) hoarding factor, which con- the consistent prevalence rates of OCD around tained hoarding obsessions and compulsions the world (Nicolini et al., 2017; Williams, (Bloch et al., 2008). These factors are similar to Chapman, Simms, & Tellawi, 2017), and the those identified by Matsunaga et al. (2008), but cross-cultural stability in OCD symptom dimen- expand the category of aggressive symptoms to sions or clusters, some evidence exists to suggest include more taboo and forbidden obsessions. the phenomenology of OCD is predominantly a In many respects, the replication of symptom neurobiological phenomenon rather than a cul- dimensions across cultures serves to consolidate tural one (Goodman, Grice, Lapidus, & Coffey, and strengthen our understanding of the homoge- 2014; Matsunaga et al., 2008). neity of OCD, often a disorder associated with Earlier in this chapter we presented findings great individuality or heterogeneity (Bloch et al., on the consistent prevalence rates of OCD across 2008; Lochner et al., 2008; Van Schalkwyk et al., diverse countries and culturally distinct commu- 2016). In addition, these studies establish the nities. Interestingly, research suggests that cross-cultural stability of OCD. However, some symptom dimensions are also consistent cross- have argued that the replicability in symptom culturally. For example, Matsunaga et al. (2008) dimensions across cultures suggests that OCD is examined symptom dimensions in a group of purely the result of universal, neurobiological 343 Japanese patients with OCD. Their research mechanisms, and the impact of culture on OCD revealed four main factors or clusters of symp- is limited (Matsunaga et al., 2008). While it is toms, including (1) contamination/washing, (2) likely that biology plays an influential role in the hoarding, (3) symmetry/repeating and ordering, organization of OCD symptoms into dimensions and (4) aggressive/checking symptoms. The that are replicable cross-culturally, the literature similarity of these symptom dimensions to suggests that cultural factors can influence the symptoms experienced by patients with OCD in frequency and distribution of OCD symptom Western cultures suggests that the symptoms are presentations. similar regardless of a person’s ethnicity or geo- The consistency in symptom dimensions graphic location. across cultures indicates that OCD is not a Expanding upon the question of cross-cultural culture-bound syndrome recognizable only symptom presentation, Bloch, Landeros-within a specific society. However, at the same Weisenberger, Rosario, Pittenger, and Leckman time, it does not rule out the relative and highly (2008) conducted a meta-analysis evaluating the nuanced contribution of cultural variables to factor structure of OCD symptoms across 21 symptom presentation. We know that OCD is not studies. They identified a four-factor symptom a condition or disorder tethered to a single cul- structure for obsessive-compulsive symptoms tural identity, and the impact of culture may not across the life span. This structure did not vary be a single determinant or absolute value. Clearly greatly between studies of English-speaking and defining the extent to which culture impacts OCD non-English-speaking participants, suggesting remains an empirical question, yet is essential to that there may not be great variation in OCD ensure that the intersection of OCD and cultural symptom presentation cross-culturally. However, identities are competently treated. More research it is worth noting that of the 21 studies included is needed to understand the way in which cultural in the meta-analysis, only eight studies (38%) factors, versus biology, drive symptom presenta- contained subjects from non-English-speaking tion within individuals with OCD. 21 Obsessive-Compulsive and Related Disorders 303

The Multifaceted Definition receive to those values, thoughts, and behaviors of Culture from individuals within and outside our communities, thereby constructing culturally bound The assessment of culture in the mental health norms of what is admissible and allowable versus domain is complex and ever-evolving. In this what is aberrant. As we strive to be culturally chapter we have predominantly focused on the competent clinicians, it is critical we not only ways in which an individual’s cultural identity consider but also understand the ways in which influences OCD symptomatology. We have cho- an individual’s culture impacts the symptoms sen to focus on individual cultural factors such as they are experiencing, the course of their illness, ethnicity, religion, race, culturally defined super- and the ways in which these forces shape their stitious beliefs, and geographically salient hot desire to seek treatment or their response to topics. These are deeply individualistic cultural interventions. forces that relate to the identity of an individual For OCD specifically, the story is nuanced. and work to shape the people that we are. Clinical and epidemiological data suggests that We would be remiss not to emphasize that cul- the presence and the main symptom dimensions ture and culturally competent care is multifac- of OCD are remarkably consistent cross- eted. There are many alternative and equally culturally. However, cultural factors do influence compelling definitions of culture that we did not the type of obsessions or compulsions an indi- touch upon in this chapter due to space con- vidual may experience and how an individual straints. For example, the culture of the clinician, makes sense of their symptoms. This chapter has the culture of mental health services, and the cul- reviewed cross-cultural prevalence rates of OCD ture of the delivery of care model all factor into and highlighted culturally informed implications culturally competent care (General, Services, & for assessment. In addition to discussing how Health, 2001). The culture of the doctor–patient treatment-seeking beliefs can be culturally influ- relationship and its role in treatment is deserving enced—and impact an individual’s decision to of a chapter of its own. Of the four domains pro- seek help—we highlighted culturally adapted posed to assess cultural issues in disease presen- assessment measures for use with clients from tation, we touched upon only one domain: the diverse backgrounds. culture of the individual. This is a limitation of this chapter. In discussing the role of cultural factors, we References have taken an individualistic approach, but it is not the only approach that one must take to pro- Altweck, L., Marshall, T. C., Ferenczi, N., & vide culturally competent care. For further Lefringhausen, K. (2015). Mental health literacy: A cross-cultural approach to knowledge and beliefs resources on the ways in which culture influ- about depression, schizophrenia and generalized anxi- ences mental health, mental illness, and mental ety disorder. Frontiers in Psychology, 6, 1272. https:// health services, we recommend reading Mental doi.org/10.3389/fpsyg.2015.01272 Health: Culture, Race, and Ethnicity: A American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Supplement to Mental Health: A Report of the Washington, DC: APA. Surgeon General (Office of the Surgeon General Amir, N., Freshman, M., Ramsey, B., Neary, E., & Brigidi, (US) et al., 2001). B. (2001). Thought-action fusion in individuals with OCD symptoms. Behaviour Research and Therapy, 39(7), 765–776. Arrindell, W. A., de Vlaming, I. H., Eisenhardt, B. M., Conclusion van Berkum, D. E., & Kwee, M. G. T. (2002). Cross- cultural validity of the Yale–Brown obsessive com- Individual cultural factors greatly influence the pulsive scale. Journal of Behavior Therapy and Experimental Psychiatry, 33(3), 159–176. https://doi. values we hold, the beliefs and thoughts we have, org/10.1016/S0005-7916(02)00047-2 and the behaviors we exhibit. Perhaps even more Asadi, S., Daraeian, A., Rahmani, B., Kargari, A., importantly, culture defines the responses we Ahmadiani, A., & Shams, J. (2016). Exploring Yale- 304 E. Cordell and R. Holaway

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Esteban V. Cardemil, Néstor Noyola, and Emily He

Depression is one of the most common and dis- mented lower rates of depression treatment abling mental disorders, with lifetime prevalence (Alegría, Chatterji, et al., 2008; González, Vega, estimates suggesting that major depressive disor- et al., 2010; Miranda & Cooper, 2004). Further, der affects approximately one in five of the US even when racial and ethnic minorities seek out general population (Kessler et al., 2005, 2006). treatment for depression, they are less likely to Moreover, many individuals experience clini- receive an adequate dosage of treatment (Fortuna, cally significant levels of depressive symptoms Alegria, & Gao, 2010; Simpson, Krishnan, that warrant treatment (Kessler, Zhao, Blazer, & Kunik, & Ruiz, 2007) and are more likely to pre- Swartz, 1997). The consequences of depression maturely drop out (Arnow et al., 2007; Warden are considerable, producing substantial human et al., 2009). suffering and loss of productivity (Chisholm Understanding the reasons for these dispari- et al., 2016; Wang, Simon, & Kessler, 2003). For ties in US mental healthcare requires a multilevel example, one study estimated the economic bur- conceptualization that acknowledges the struc- den of major depressive disorder on US society to tural contributors at the levels of society, the be approximately $210.5 billion in 2010 healthcare system, and training and workforce (Greenberg, Fournier, Sisitsky, Pike, & Kessler, development (Cardemil, Nelson, & Keefe, 2015). 2015). Despite these very real structural factors that Although there exist numerous efficacious impede the amelioration of these disparities, psychosocial and pharmacologic treatments for some progress has been made in a number of depression, many individuals experiencing areas, including research and clinical attention to depression do not receive adequate treatment. the incorporation of cultural considerations into Indeed, various studies have suggested that fewer the treatment of depression. than half of individuals in need receive any type In this chapter, we review the important prog- of specialty psychiatric care (Kessler, Merikangas, ress that has been made in the development and & Wang, 2010). These numbers are even worse evaluation of psychological treatments for for individuals from racial and ethnic minority depression for racial and ethnic minorities. We groups, for whom research has consistently docu- first briefly summarize the epidemiological research on depression among different racial E. V. Cardemil (*) · N. Noyola · E. He and ethnic groups, focusing on Latinx, Black and Frances L. Hiatt School of Psychology, Clark African Americans, Asian Americans, and University, Worcester, MA, USA American Indians. We then review the evidence e-mail: [email protected]; [email protected]; base supporting the efficacy of psychotherapy for [email protected]

© Springer Nature Switzerland AG 2020 309 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_22 310 E. V. Cardemil et al. depression with racial and ethnic minorities and prevalence of MDD, as compared to European then conclude with recommendations for how Americans (Hasin et al., 2005). clinicians and researchers can help ameliorate Importantly, within these general patterns, these disparities. researchers have also found incongruent results, underscoring the need for more nuanced studies. For example, a meta-analysis found elevated Brief Epidemiological Review rates of depressive symptoms among Latinx as of Depression Among Racial/Ethnic compared to White Americans (Menselson, Minority Groups Rehkopf, & Kubzansky, 2008). The National Health and Nutrition Examination Survey Epidemiological research over the past 20 years (NHANES) also found elevated rates of clini- has found some notable patterns in the preva- cally significant depressive symptoms among lence of depression across racial and ethnic both Latinx and African American adults (Riolo, groups in the USA. In particular, researchers Nguyen, Greden, & King, 2005). Moreover, the have generally found similar, or lower, rates of NSAL documented worse course and persistence depression among Latinx, Black and African of MDD among African Americans than White Americans, and Asian Americans, as compared Americans, despite lower prevalence rates with White Americans (Alegría, Chatterji, et al., (Williams et al., 2007). Finally, in contrast to the 2008; Hasin, Goodwin, Stinson, & Grant, 2005; elevated risk for depression among American Jackson et al., 2011). For example, using data Indians reported by the NESARC, the American from the National Latino and Asian American Indian Service Utilization, Psychiatric Study (NLAAS) and the National Comorbidity Epidemiology, Risk and Protective Factors Survey Replication (NCS-R), Alegría, Canino, Project (AI-SUPERPFP) found lower lifetime et al. (2008) estimated the lifetime prevalence of prevalence rates of MDD among two American major depressive disorder to be 15.2% among Indian tribes (7.8% and 10.7%) than in the gen- Latinxs, compared to the estimated prevalence of eral US population (Kaufman et al., 2013). 22.1% for non-Latinx Whites. Similarly, the It is likely that some of these incongruent find- National Survey of American Life (NSAL) found ings can be explained by differences in sample the lifetime prevalence rate of major depressive composition, given the considerable evidence for disorder (MDD) to be 10.4% for African within-group variability in depression. We now Americans, 12.9% for Caribbean Black discuss some of this variability. Americans, and 17.9% for White European Americans (Williams et al., 2007). Another large- scale epidemiological study—the National Contextual Factors and Within-Group Epidemiological Survey on Alcoholism and Variability Related Conditions (NESARC)—also found lower lifetime risk for MDD among Asian Much of the variability in depression has been Americans, Latinxs, and Black Americans, as investigated along important contextual factors compared to European Americans (Hasin et al., that differentiate individuals within particular 2005). With regard to American Indians, there racial and ethnic groups. These context factors has been very little psychiatric epidemiological include national origin, generational status and research. However, the NESARC reported find- acculturation, socioeconomic status, gender, and ings from eight geographically contiguous reser- sexual orientation. vations that were at odds with this general pattern of lower risk for depression among racial and National Origin ethnic minorities. In particular, the NESARC Considerable evidence has found variability in found that American Indian and Alaska Native depression by national origin. For instance, groups had 1.5 times greater odds of lifetime among Latinxs, higher rates of depression have 22 Cultural Considerations in Treating Depression 311 been documented among Latinxs of Puerto American and Black Caribbean Americans, Rican origin and lower rates among Mexican- Williams et al. (2007) found higher rates of life- origin Latinxs (Alegría, Canino, et al., 2008; time MDD among Black Caribbean Americans, González, Tarraf, Whitfield, & Vega, 2010; 65% of whom were born outside the USA. Wassertheil-Smoller et al., 2014). Similarly, a Beyond generational status, researchers have meta-analysis of 58 studies in nonclinical/com- also investigated the relationship between accul- munity settings found significantly lower rates turation and depression. Despite the extensive of depression among Chinese Americans research in this area, the literature has yielded (15.7%) than among Korean Americans (33.3%) mixed findings. A few studies have found that and Filipino Americans (34.4%) (Kim, Park, greater acculturation is associated with greater Storr, Tran, & Juon, 2015). In addition, research risk for depression among Latinx, Black, and has found that refugees from Southeast Asia Asian Americans (e.g., Burnett-Zeigler, may be at especially heightened risk for depres- Bohnert, & Illgen, 2013). However, other stud- sive disorder compared to other Asian American ies have not found this association (Buddington, groups (Wong et al., 2006). For Black 2002; Cobb, Xie, Meca, & Schwartz, 2017). In a Americans, national origin has also been found literature review of 86 studies, Koneru, de to be related to variability in depression rates, Mamani, Flynn, and Betancourt (2007) found with higher lifetime prevalence of MDD among considerable heterogeneity in the relationship Caribbean Americans (12.9%) as compared to between acculturation and depression for African Americans (10.4%) (Williams et al., Latinxs and Asian Americans, while a recent 2007). And although the AI-SUPERPFP did not meta-analysis of 38 studies found a small sig- find differences in lifetime prevalence of major nificant negative relationship between accultur- depressive episode between a southwest and a ation and depression for Asian Americans northern plains tribe, they did find differences in (Gupta, Leong, & Valentine, 2013). In contrast levels of depressive symptoms (Beals et al., to the equivocal finding on acculturation and 2005). depression, research has consistently found acculturative stress to be positively correlated Generational Status and Acculturation with depression (Constantine, Okazaki, & Research on immigration has generally found Utsey, 2004; Hovey, 2000). lower risk for depression among first-generation immigrants compared to subsequent generations Socioeconomic Status (Alegría, Canino, et al., 2008; Zhang, Fang, Wu, Overall, research suggests that socioeconomic & Wieczorek, 2013). Indeed, the pattern of better status is associated with depressive symptoms overall physical and mental health among immi- among racial/ethnic minorities. For example, a grants has been termed the healthy immigrant study using data from the NCS-R, NSAL, and paradox (Alcántara, Estevez, & Alegría, 2017). NLAAS found that among Latinx men, being Among Latinxs, this pattern has been most evi- out of the labor force was found to be associated dent in Latinxs of Mexican descent (Alegría, with higher risk for depression (Gavin et al., Canino, et al., 2008; Alegría et al., 2007; 2010). Similarly, for African Americans, unem- González, Tarraf, et al., 2010). Similar patterns ployment has been associated with higher rates have been identified among Asian Americans of depression (McKnight-Eily et al., 2009). (Jackson et al., 2011; John, De Castro, Martin, Across Asian American groups in the NLAAS Duran, & Takeuchi, 2012; Lau et al., 2013). sample, those who were unemployed had the Research on immigration among Black highest rates of any mental health disorder, Americans is more limited, but one study using including depression, as compared to white-col- data from the NSAL yielded results inconsistent lar, blue-collar, and service workers, although with the healthy immigrant paradox. In particu- this finding was not significant after adjusting lar, when comparing depression between African for age and gender (John et al., 2012). 312 E. V. Cardemil et al.

Nevertheless, another research study from pri- Sexual and Gender Minorities mary care settings with Chinese immigrants Despite the growth in attention to sexual minority from low socioeconomic backgrounds has found populations, there exists a marked dearth of that they are at high risk for major depressive research on depression among LGBTQ racial/ disorders (Chung et al., 2003). ethnic minorities in the USA. This is unfortunate However, other research suggests that there given that approximately 42% of LGBTQ- may be important nuances to this pattern. For identified adults identify as racial/ethnic minori- example, using data from the NSAL, Assari ties (The Williams Institute, 2019). Similarly, the (2017) found that high income was a risk factor Centers for Disease Control and Prevention (CDC) for major depressive disorder for African Behavioral Risk Factor Surveillance System American men after controlling for the effects of (BRFSS) estimates that 45% of transgender indi- other socioeconomic status indicators such as viduals in the USA identify as racial/ethnic education and employment. Another study that minorities (Flores, Brown, & Herman, 2016). also used data from the NSAL suggests that The limited research in this area suggests that employed Black Caribbean Americans have LGBTQ racial/ethnic minorities experience higher rates of MDD compared to their unem- higher risk for depression when compared to ployed counterparts, a pattern that was opposite their heterosexual racial/ethnic minority counter- that found for African Americans (Williams parts, but that this risk is similar to or lower than et al., 2007). that of LGBTQ non-Latinx White individuals (Cochran, Mays, Alegria, Ortega, & Takeuchi, Gender 2007; Meyer, Dietrick, & Schwartz, 2008). For Research has consistently documented elevated example, in a recent study using nationally repre- risk for depression in women, as compared with sentative data from the National Epidemiologic men (Salk, Hyde, & Abramson, 2017; Zhang Survey on Alcohol and Related Conditions-III et al., 2013). A recent meta-analysis examining (NESARC-III), researchers found that sexual gender and depression found similar patterns minority racial/ethnic minorities, compared to across different racial/ethnic groups with regard their heterosexual racial/ethnic minority counter- to both major depression and depressive symp- parts, were at a heightened risk for past-year toms (Salk et al., 2017). For instance, using data major depressive episode and dysthymia from the NLAAS, Lorenzo-Blanco and Cortina (Rodriguez-Seijas, Eaton, & Pachankis, 2019). (2013) found that Latina women were twice as However, when compared to non-Latinx White likely to meet criteria for lifetime MDD as Latino sexual minorities, Black and Latinx sexual men (19.8% vs. 10.9%). Similarly, findings from minorities experienced a lower risk for past-year the NSAL suggested that Black American women major depressive episode and dysthymia had twice the rate of MDD compared to Black (Rodriguez-Seijas et al., 2019). Unfortunately, American men, although no differences were there is a virtual absence of epidemiological found between Caribbean American men and research on depression among transgender peo- women (Williams et al., 2007). Findings using ple of color in the USA (Hoffman, 2014). One the three surveys from the CPES (NCS-R, NSAL, study using data from the Center for Collegiate and NLAAS) found that Chinese immigrant and Mental Health dataset suggests that transgender US-born Chinese women had higher rates of and gender diverse people of color may experi- depression compared to Chinese immigrant and ence higher rates of depression compared to the US-born Chinese men for 12-month MDD and non-Latinx White counterparts (Lefevor, Janis, lifetime MDE (Tan, 2014). For American Indians Franklin, & Stone, 2019). However, another and Alaska Natives in the NESARC sample, study found that levels of depressive symptoms women (22.9%) were more likely to meet criteria did not differ between non-Latinx White trans for MDD compared to men (15.1%) (Brave Heart individuals and trans racial and ethnic minorities et al., 2016). (Budge, Thai, Tebbe, & Howard, 2016). 22 Cultural Considerations in Treating Depression 313

Family Context some benefit to be gained by understanding these Research suggests that family context influences contextual factors in isolation, it is also important risk for depression (e.g., Sarmiento & Cardemil, for researchers to examine multiple contexts at 2009). For example, using data from the NLAAS, once. For example, some research has found dif- Park, Unützer, and Grembowski (2014) found ferences in family cultural conflict and cohesion that family cohesion was associated with a across racial/ethnic minority groups by genera- decreased risk for depression among Latinx and tion status (Chang, Natsuaki, & Chen, 2013). Asian older men, but not women. Among African Similarly, the effects of social and family rela- Americans, a study using data from the NSAL tionships on depression may differ between found that higher frequency of contact with fam- Black Caribbean Americans and African ily members and higher emotional support from Americans as a result of migration-related factors extended family among African Americans were (Lincoln & Chae, 2012). associated with lower levels of depressive symptoms (Chatters, Nguyen, Taylor, & Hope, 2018). Similarly, a study with African American college Depression Treatment for Racial students found that family support and family and Ethnic Minorities cohesion were associated with lower levels of depressive symptoms (Harris & Molock, 2000). There has been very little research examining the Relatedly, family conflict has been found to be efficacy of depression treatment for racial and associated with depression among African ethnic minorities (Mak, Law, Alvidrez, & Perez- Americans, Latinxs, and Asian Americans Stable, 2007). A recent review by Polo et al. (Constantine et al., 2004; Park et al., 2014; Ying (2019) noted that only 16.7% of depression trials & Han, 2007). since 1981 focused on racial or ethnic minority populations. Of these, none focused specifically Summary on individuals from Asian American and Native Epidemiological research over the last 20 years American backgrounds. Moreover, only 2% of has found notable patterns in depression rates trials reported treatment effects across racial/eth- across racial and ethnic groups in the USA. In nic groups, and only 11% reported ethnicity particular, researchers have generally found simi- moderation analyses. Thus, our understanding of lar, or lower, rates of depression among Latinx, the efficacy of treatment for depression among Black and African Americans, and Asian racial and ethnic minorities is limited. Americans, but higher rates among American Nevertheless, there has been some research Indians, as compared with non-Latinx White that has helped inform the field’s understanding Americans (Alegría, Chatterji, et al., 2008; Hasin of effective treatments, particularly for Latinx et al., 2005; Jackson et al., 2011; Kaufman et al., groups. Although much of the work with Latinxs 2013). Focusing solely on these broad patterns has been with cognitive behavioral therapy can be problematic, however, as it runs the risk of (CBT) (e.g., Escobar & Gorey, 2018; Pineros- missing important within-group variability. Some Leano, Liechty, & Piedra, 2017), a recent sys- of this within-group variability is consistent with tematic review concluded that there is evidence research findings in the general population (e.g., for the efficacy of problem-solving therapy higher rates of depression among women, those (PST), interpersonal psychotherapy (IPT), and from lower SES backgrounds, and those with behavioral activation (BA)—in addition to more family conflict). However, some of the pat- CBT—in treating depression among Latinxs terns have been unexpected and warrant more (Collado, Lim, & MacPherson, 2016). For examination of mechanisms (e.g., differences in example, in a randomized controlled trial of BA depression by national origin, lower rates among with 43 depressed, Spanish-speaking Latinx immigrants, and mixed patterns among sexual adults, Kanter et al. (2015) found comparable minorities of color). Although there is likely improvement in depression as treatment as 314 E. V. Cardemil et al. usual, but significantly better treatment engage- the majority of whom were Latina or African ment and retention. Moreover, their findings American. Participants were randomly assigned indicated that when participants attended at to one of three conditions: individual CBT, anti- least 5 of 12 sessions, the improvement in depressant medication, or usual care. Those depressive symptoms was significantly larger women who received CBT or antidepressant for those participants who received BA. In a medication also participated in a pre-interven- follow-up study, the authors found evidence that tion educational workshop that provided an ori- acculturative stress might be related to treat- entation to the treatment process. Results ment retention (Santos et al., 2017). Another indicated that both CBT and antidepressant study of BA with Latinx found evidence that it medication produced significantly greater led to significantly greater improvement in improvement in depressive symptoms than depressive symptoms, as compared with sup- usual care. Moreover, these results extended portive counseling (Collado, Caldern, through 1-year follow-up (Miranda et al., 2006). MacPherson, & Lejuez, 2016). Similarly, Johnson et al. (2019) evaluated the For African Americans, the body of research effectiveness of group IPT for incarcerated is more limited than for Latinxs. Some emerg- adults with major depression. Of the 181 par- ing research has found support for the effective- ticipants enrolled in the study, 20% were African ness of both CBT and IPT (Bernecker, Coyne, American and 19% were Latinx. Results indi- Constantino, & Ravitz, 2017; Gregory Jr., cated that IPT led to significantly greater 2016). In a recent meta-analysis examining the improvement in depressive symptoms, hope- effectiveness of CBT with adults of African lessness, and posttraumatic symptoms as com- descent, Gregory Jr. (2016) reported a medium pared to prison treatment as usual. These studies effect size (Hedge’s g = 0.69). However, there have not reported treatment by ethnicity interac- exist significant limitations to research in this tions, however, most likely due to insufficient area, with only ten studies meeting inclusion power. criteria, only five using randomized controlled Among Asian Americans, little research trial methodology, and only three explicitly exists examining the effectiveness of treatments diagnosing major depressive disorder. for depression (Hwang, Ho, Chan, & Hong, Nevertheless, this limited research is promising. 2018; Sue, Cheng, Saad, & Chu, 2012), and we For example, a small randomized controlled could find no research examining the effective- trial examining the delivery of CBT to African ness of depression treatment among American American dementia caregivers found that both Indians. Among Asian Americans, only two face-to-face and telephone-based delivery were studies have been published examining associated with significant improvements in CBT. Both studies focused on Chinese depressive symptoms (Glueckauf et al., 2012). Americans, and both found some support for its Similarly, a review of IPT found some prelimi- effectiveness (Dai et al., 1999; Hwang et al., nary support for its effectiveness with African 2015). In the more rigorous of these two stud- Americans (Bernecker et al., 2017). But again, ies, Hwang et al. (2015) compared a culturally the limitations are significant, including only adapted version of CBT with standard CBT three studies with small samples and high attri- with a sample of 50 Chinese American adults tion from the study. seeking treatment for depression in two com- The strongest support in favor of both CBT munity clinics in California. Although there and IPT in the treatment of depression for was a slight advantage to the culturally adapted Latinxs and African Americans has come from version of CBT (i.e., less dropout, more rapid studies with heterogeneous samples. For exam- rate of improvement in depressive symptoms), ple, Miranda et al. (2003) conducted a random- both versions of CBT produced significant ized controlled trial evaluating depression improvement in depressive symptoms over treatment in a sample of low-income women, 12 weeks. 22 Cultural Considerations in Treating Depression 315

Commonalities Across Depression (78.8%), which suggests that modifying CBT for Treatments telephone delivery may improve access to care for low-income Latinxs. Similarly, in a pilot study, Across the different studies evaluating depres- Glueckauf et al. (2012) found preliminary evi- sion treatment, we identified a few commonali- dence for the effectiveness of telephone-based ties. In particular, many of the researchers who CBT among depressed African American caregiv- evaluated CBT made adaptations to accommo- ers of individuals with dementia. Importantly, date particular aspects deemed important to the they found evidence to suggest that the effect of different racial and ethnic groups in the studies. treatment was smaller for face-to-face CBT than For instance, at a minimum, researchers working for telephone-based CBT. with participants for whom English was not the There was variability in the extent to which preferred language made adaptations based on these adaptations were guided by any conceptual language (e.g., Collado, Lim, et al., 2016; Hwang framework (e.g., Domenech-Rodríguez & et al., 2015). Beyond language, there were other Bernal, 2012; Hwang, 2012), and only Hwang adaptations that researchers made to make the et al. (2018) compared an adapted intervention to intervention more relevant to the participants. In a standard intervention. Nevertheless, this adap- particular, several researchers explicitly noted the tation work builds on a growing literature docu- efforts to incorporate cultural values into the menting the effectiveness of cultural adaptations intervention (Hwang et al., 2018; Kanter et al., (Benish, Quintana, & Wampold, 2011; Griner & 2015). Smith, 2006). A recent meta-analysis reported a Several studies also described how they made medium average effect size (d = 0.50) across 99 other adaptations in recognition of the fact that different studies (Soto, Smith, Griner, Domenech- many of their participants came from low-income Rodríguez, & Bernal, 2018). Moreover, the backgrounds and had less formal education (e.g., authors found evidence that studies that made Miranda et al., 2003). For example, Kanter et al. language adaptations, used culturally consonant (2015) noted that they adapted their BA interven- metaphors, and implemented culturally relevant tion by simplifying the treatment rationale, rely- techniques yielded larger effect sizes than those ing less on homework, removing certain that did not. acronyms, and increasing the emphasis on family and community resources. A few researchers expanded the emphasis on psychoeducation and Moving Forward therapy orientation prior to beginning the actual treatment (Hwang et al., 2018). For example, in Although limited, the research examining depres- one study examining depression treatment for sion treatment of racial and ethnic minorities has low-income women, participants could receive up yielded promising results, and there is reason to to four psychoeducation sessions about depres- be optimistic that both research and clinical work sion and treatment (Miranda et al., 2003, 2006). in this area will contribute to efforts to ameliorate One promising area for future research is the use the persistent disparities in access to mental of technology to address inequities in access to healthcare. However, it is unclear whether treatment. For instance, Alegría et al. (2014) increasing access to mental health services will found that a telephone-based combined CBT and be best served by the development and dissemi- care-management intervention for low-income nation of numerous cultural adaptations of Latinxs associated with meaningful reductions in manual-based treatments for different disorders depressive symptoms and functional impairment and populations. Beyond the fact that there is as compared to usual primary care for depression. likely a limited number of interventions in which Importantly, they found that more participants ini- clinicians can acquire expertise, it can be difficult tiated mental health care in their phone interven- to ascertain which groups cohere sufficiently to tion (89.7%) than in the face-to-face intervention warrant an adaptation. 316 E. V. Cardemil et al.

As such, it is critical to recognize that thera- approach (e.g., Adamés et al., 2018; Owen et al., pists will play important roles in the application 2016; Torres, Mata-Greve, Bird, & Hernandez, of these interventions in culturally sensitive ways 2018). One strength of this approach is that it (e.g., Lakes, López, & Garro, 2006). Indeed, allows for an examination of how systems of there is growing evidence that therapist cultural privilege and oppression may shape risk factors competence is associated with positive outcomes for depression in unexpected ways. For example, (e.g., Soto et al., 2018). The advantage of focus- in a study of Chinese, Filipino, and Vietnamese ing on therapist cultural competence is that thera- women in the USA, Lau et al. (2013) found that pists can more readily recognize and work with Asian American women born in the USA were at the heterogeneity that exists within the different greater risk for exposure to discrimination, ele- racial ethnic groups, some of which we summa- vated family conflict, and reduced family cohe- rized at the outset of this chapter. sion, while at the same time benefiting from However, we believe that attending to this het- higher social status and family support compared erogeneity is likely to be insufficient in address- to immigrant Asian women. Thus, an intersec- ing the persistent disparities that exist in mental tional approach foregrounds considerations of healthcare. Focusing primarily on multiple iden- the multiple ways in which people experience tities and not on the very real structural factors both privilege and oppression to shape their related to oppression and marginalization is experiences. unlikely to lead to lasting change. As such, we Another important strength is that intersec- believe that clinicians would do well to consider tionality approaches also allow for a better under- the use of an intersectionality lens through which standing of the many strengths that racial/ethnic to view within-group heterogeneity and its rela- minorities develop in the face of marginalization, tion to disparities in mental healthcare (Cole, such as resilience and coping. For example, in a 2009; Crenshaw, 1991). Contemporary intersec- study on LGBTQ people of color’s experiences tionality perspectives have their roots in Black in their communities, Ghabrial (2017) found that, feminist scholarship and activism, which have by embracing and developing a positive outlook critiqued the narrow focus on single dimensions on specific marginalized identities, participants of identity and oppression separately from each were also able to develop acceptance and empow- other (e.g., focusing on racism without attending erment of their other marginalized identities. to how sexism shapes racism) (Collins, 2015; Similarly, a qualitative study aimed at better Moradi, 2017). Intersectionality approaches understanding the intersection of racism and sex- attend to the multiple, intersecting identities of ism among African American women found that individuals (particularly for those who belong to African American women actively employ col- marginalized groups), as well as to the underly- lective, self-protective, and resistance coping ing systems of privilege and oppression strategies in the face of gendered racial microag- (Rosenthal, 2016). Importantly, intersectionality gressions (Lewis, Mendenhall, Harwood, & approaches move beyond simplistic within-group Huntt, 2013). These examples remind us that variability in experience by explicitly consider- despite the multiple forms of oppression that ing the ways in which different systems of privi- communities of color experience, there remains lege and oppression work together to impact the remarkable strength and agency that needs to be well-being, health, and resources available to recognized. individuals from marginalized groups (Adamés, Ultimately, because of the persistent nature of Chavez-Dueñas, Sharma, & La Roche, 2018; disparities that continue to affect many commu- Patil, Porche, Shippen, Dallenbach, & Fortuna, nities, it is likely that multiple approaches will be 2018). needed to address and dismantle them. While Research in the application of intersectional- some of these efforts will lie in the realm of pol- ity frameworks to clinical work is still in its early icy, there remains much that can be accomplished phases, but there is growing interest in this in the delivery of mental healthcare when we 22 Cultural Considerations in Treating Depression 317 acknowledge that powerful systemic and struc- findings with a structured interview. The American Journal of Psychiatry, 162(9), 1713–1722. tural forces affect so many different communi- Benish, S. G., Quintana, S., & Wampold, B. E. (2011). ties. Some of this work will occur at the level of Culturally adapted psychotherapy and the legitimacy the intervention (e.g., cultural adaptations) and of myth: A direct-comparison meta-analysis. Journal some at the level of the therapist (i.e., cultural of Counseling Psychology, 58(3), 279–289. Bernecker, S. L., Coyne, A. E., Constantino, M. J., & competence). An intersectional approach has Ravitz, P. 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There is well-documented racial, ethnic, and socio- in breathing during sleep and excessive daytime economic health disparities with both non-White sleepiness is common and is associated with and other socioeconomically disadvantaged popu- medical morbidities including heart disease and lations shown to have worse outcomes across a stroke (Monahan & Redline, 2011). Grandner range of health problems (Adler & Rehkopf, 2008; et al. (2012) found that people who report poor Center for Disease Control and Prevention, 2011; health or complain of depressive symptoms are at Smedley, Stith, & Nelson, 2003). The reason for higher risk for experiencing sleeping problems. the health disparities is likely facilitated by a com- Persons suffering from sleep disturbances are bination of physiological, structural, and behav- more likely to suffer from chronic health prob- ioral differences across populations (Adler & lems such as diabetes, obesity, chronic pain, heart Rehkopf, 2008; Smedley et al., 2003). disease, and gastrointestinal problems (Taylor Understanding the causes of health disparities et al., 2007). Women are more likely to report across racial/ethnic groups is an important public insomnia symptoms compared to men and 50% health cause. One of the important health dispari- of adult’s aged 65 and older report problems with ties to address is poor sleep quality or insufficient sleep (Ohayon, 2002; Ohayon, Zulley, sleep. A report from the Institute of Medicine iden- Guilleminault, Smirne, & Priest, 2001). These tified “sleep deprivation and sleep disorders,” as a findings are important for persons from various major unmet public health problem and American ethnic/racial groups and/or from differing socio- health crisis (Colten & Altevogt, 2006; Office of economic groups because this could place them Disease Prevention and Health Promotion, 2011). at higher risk of chronic health problems. Cultural Insomnia, described by problems falling considerations and sleep problems are a specific asleep and/or maintaining sleep is a very com- area of significant health concerns, but sadly little mon problem impacting nearly 60 million people is known of the effect of ethnicity on sleep. The with significant health-care costs and burden 2003 National Institute of Health National Sleep (Center for Disease Control and Prevention, Disorders Research Plan (NSDRP) showed 2011). Obstructive sleep apnea defined by pauses reported differences in sleep architecture (i.e., stages of sleep) and major health disparities between different ethnic/racial groups. NSDRP R. Gentry (*) Integrated Sleep & Wellness, Reno, NV, USA showed that those who are socioeconomically disadvantaged are more likely to have poor sleep Psychiatry and Behavioral Sciences, University of Nevada School of Medicine, Reno, NV, USA environments such as overcrowded or too hot or e-mail: [email protected] cold, which could negatively impact sleep.

In regard to racial/ethnic disparities, studies age, gender, and socioeconomic status were at have shown that they do exist in disturbed sleep higher risk for insomnia than Caucasians. They (Gamaldo, McNeely, Shah, Evans, & Zonderman, also found that Hispanic, Central American, and 2015; Hale & Do, 2007; Stamatakis, Kaplan, & African American youth were at a higher risk for Roberts, 2007). African Americans report shorter hypersomnia than Caucasians. They concluded sleep duration and reduced sleep quality com- that minority status might impact the risk for pared to other racial groups (Mezick et al., 2008; developing sleeping problems. Further, pregnant Whinnery, Jackson, Rattanaumpawan, & Latinas are also substantially impacted by insom- Grandner, 2014). The Grandner et al. (2013) nia, and insomnia symptoms have been noted to study found non-Hispanic Blacks had greater dif- be particularly high among Latinas with depres- ficulty falling and staying asleep, whereas sion (Manber et al., 2013). Moreover, Latinos Hispanics were more likely to snore (possible have been noted to report poorer sleep practices sign of sleep apnea) compared to non-Hispanic relative to African American and Asian students Whites. In 2014, the Center for Disease Control (Gaultney, 2010). and Prevention looked at short sleep duration in Loredo et al. (2010) reviewed the small litera- adults as defined as less than 7 h of sleep per 24-h ture on Latinos and sleep and indicated that the period and found that short sleep duration was high prevalence of risk factors in Hispanics (i.e., less common among respondents aged ≥65 years obesity, diabetes, living in the inner city, use of (26.3%) compared with other age groups. The alcohol, poor sleep hygiene) and the negative age-adjusted prevalence of short sleep duration effects of acculturation, especially on the young, was higher among Native Hawaiians/Pacific suggested that the prevalence of sleep-related Islanders (46.3%), non-Hispanic Blacks (45.8%), disorders such as insomnia and sleep apnea is multiracial non-Hispanics (44.3%), and American likely high among Hispanics. The literature also Indians/Alaska Natives (40.4%) compared with suggests that acculturation to the US lifestyle is non-Hispanic Whites (33.4%), Hispanics positively related to sleep difficulties among this (34.5%), and Asians (37.5%). Short sleep preva- group (Manber et al., 2013; Seicean, Neuhauser, lence did not differ between men and women. Strohl, & Redline, 2011). This has been sup- Newer studies suggest that sleep disturbances ported in research that has identified that US-born such as undiagnosed sleep apnea and insomnia Hispanic/Latina immigrants were more likely to occur more frequently among racial/ethnic report sleep complaints than their first-generation minorities. Chen et al. (2015) found that after ethnic counterparts (Hale, Troxel, Kravitz, Hall, adjustment for sex, age, and study site, African & Matthews, 2014). But still little is known on Americans were most likely to have short sleep other important sleep variables in Hispanics such duration of less than 6 h and more likely than as sleeping habits, beliefs, or attitudes about Whites to have sleep apnea, poor sleep quality, sleep or knowledge of sleep disorders. This is and daytime sleepiness. Hispanics and Chinese because the majority of research has been were more likely than Whites to have sleep apnea obtained in non-Hispanic White populations and and short sleep duration. Ford, Cunningham, African Americans making it difficult to general- Giles, and Croft (2015) found similar prevalence ize to other racial groups (Loredo et al., 2010). rates of insomnia in the National Health Interview So given the high prevalence of sleep disor- Survey among Whites and Hispanics (approxi- ders in general, it is important to unravel why mately 19% for both), and other researchers have race and ethnicity differences exist within sleep. found higher rates for insomnia among Latinos. Grandner, Williams, Knutson, Roberts, and For example, Hispanic youth were significantly Jean-Louis (2016) proposed that race/ethnicity more likely to report insomnia symptoms (42.0%) differences exist regarding sleep in that differ- than non-Hispanic White youth (30.4%) (Blank ing social and environmental factors may play a et al., 2015). Roberts, Roberts, and Chen (2000) role in different beliefs and attitudes about reported that Hispanic youth after adjusting for sleep. Adenekan et al. (2013) proposed that psy- 23 Cultural Considerations and Sleep 325 chosocial factors such as employment and health care, which can also impact sleep if the finances have role in sleep disparities in the person cannot receive appropriate treatment in USA, but also suggested that genetics or socio- the case of sleep apnea. economic status could also be contributing vari- Grandner et al. (2013) found that those with ables that mediate the racial differences seen in household income less than $20,000 were more health risk related to sleep. For instance, differ- likely to report multiple symptoms of sleep disor- ential anatomic risk factors among racial groups ders. It was suggested that changes in sleep are have indicated possible racial differences in the not related to income, but rather what the income genetics of sleep (Buxbaum, Elston, Tishler, & can buy for that family. So that may mean better Redline, 2002; Matthews et al., 2010; Villaneuva, access to health care, better neighborhoods, and Buchanan, Yee, & Grunstein, 2005). African healthier sleep environments that are associated Americans with depression are shown to have with higher incomes may have an impact on more stage 2 sleep, longer latency to rapid eye sleep. If various ethnic groups are likely to have movement (REM) sleep, and less REM sleep lower incomes or live in poverty compared to than White counterparts (Giles, Perlis, Reynolds, Caucasian, this may create a health disparity & Kupfer, 1998). These data imply that racial across race based on socioeconomic status that ethnic factors and genetic factors may impact needs to be addressed. sleep related outcomes (Giles et al., 1998). Few studies have examined beliefs and atti- However, still more research needs to be done to tudes about sleep that differ across race/ethnic clarify the relationship between sleep and/or groups (Grandner et al., 2016). The few studies sleep architecture among different ethnic that have been conducted looked at beliefs and populations. attitudes in African Americans have shown that The social-ecological model of sleep and African Americans with a high risk of obstructive health (first presented by Grandner et al. (2010)) sleep apnea had higher scores on the dysfunc- describes how sleep is determined by individual- tional beliefs and attitude scale compared to level factors, which are embedded within those who were not at a high risk (Pandey et al., social-level factors, which themselves are 2011). embedded within societal-level factors. This is Less work has been done in Hispanics and suggesting that our individual beliefs and Latino groups, but sleep knowledge has been behaviors are entrenched within the aspects of evaluated among Mexican Americans and found the environment including our individual cul- that similar rates of knowledge were seen for ture suggesting that sleep is not only a physio- insomnia (Sell et al., 2009). It is likely that a logical experience but also a social and cultural number of factors may impact ethnic/racial dif- experience as well (Grandner et al., 2012) This ferences in sleep-related beliefs and sleep knowl- may be the reason to why sleep varies widely edge. Grandner et al. (2016) suggested that among cultures and ethnicities. Take, for socioeconomics, differences in work/home/ instance, bed sharing and co-sleeping with chil- neighborhood environments, acculturation, bed- dren and other family members, which varies room environment including bed sharing, access about cultures and also ethnic groups. Sleeping to health care, trust in medical professionals, or with a young child or aging parent could impact traditional medicine all may play a role in individual sleep patterns and may be associated impacting sleep beliefs and behaviors. For with lower incomes. Those in poverty are more instance, the role of the physical environment likely to report sleep problems, compared to likely differ among race/ ethnicity. This includes those not in poverty (Grandner et al., 2010; the home environment, but also work environ- Patel, Grandner, Xie, Branas, & Gooderatne, ment as well. In the home, more crowded house- 2010). This is because of crowded living envi- holds tend to be associated with insufficient ronments, longer or more demanding work sleep, and co-sleeping likely impacts sleep qual- schedules, and/or lack of access to quality ity negatively (Grandner et al., 2016). Sleep may 326 R. Gentry be more of a luxury given the socioeconomic sleep study or polysomnography (PSG) may be demands and one must consider the impact of needed to make the diagnosis. The PSG is usually shift work as ethnic minorities are more likely to ordered by a medical provider with specialized work longer hours and work more jobs com- training in sleep medicine and is a comprehen- pared to non-minorities. Unlike physicians or sive recording of the biophysiological changes military that may also work around the clock, that happen during sleep. It is usually performed these positions usually come with better access at night in a sleep lab and monitors brain activity to health care. In the case of minorities, their (EEG), heart rhythm (ECG), eye movements work schedules may be the case of not having (EOG), and muscle activity (EMG) during sleep. better options and their long work hours and PSG is needed to make a diagnosis of sleep schedules likely impact their opportunities for apnea, and if apnea is found, the treatment is sleep. Further, they are more likely to work most commonly the CPAP or continuous positive physically demanding jobs, and it has been airway pressure. Sadly, the rates of CPAP com- shown that individuals with more manual labor pliance only range from 30% to 60% despite jobs are more likely to report shorter sleep dura- numerous advances in machine dynamics such as tions (Barilla, Corbitt, Chakravorty, Perlid, & improved comfort in masks and quieter pumps Grandner, 2013). (Weaver & Grunstein, 2008; Weaver & Sawyer, Given the complexity of sleeping problems in 2010). Minorities and low SES populations may ethnic minorities comes the even greater chal- be a higher risk for more severe sleep apnea than lenge of identifying the problem and prescribing affluent populations possibly related to increased treatment. Making the diagnosis of a specific exposure to environmental toxins. Of concern is sleep disorder is based on patients’ subjective the rates of CPAP compliance can be even lower report of the sleeping problem and the judgment in ethnic minorities. Billings et al. (2011) found of the clinician. Thus, it is important that clini- that CPAP adherence differed significantly by cians can recognize the difference between acute race at 3 months but not by other social factors sleep problems and more chronic sleeping prob- such as education, employment, and marital or lems such as insomnia and sleep apnea, which smoking status. They found that African commonly occur together. Historically, the most American had a significantly lower nightly use of common approach to treatment of sleep distur- CPAP suggesting that inequities remain despite bance is often prescription medications, but this attempts to standardize treatment. More research comes with a cost for the consumer. The concern is needed to better understand difference in CPAP is not only the fact that sleep aids have side use among various ethnic groups so appropriate effects, such as memory loss, drowsiness, dizzi- interventions can be designed to improve adher- ness, and loss of coordination and balance (espe- ence rates in at-risk populations. cially in elderly), but in some cases they may If insomnia persists, sleeping medications are only work slightly better than a placebo (The no longer considered the recommended treat- Truth About Sleeping Pills, 2015). Sleeping aids ment, but rather a treatment called cognitive should generally be used for short-term use (few behavioral therapy for insomnia (CBT-I). Both weeks), but people are often using them for years, the American Academy of Sleep Medicine thus becoming dependent on them and increasing (AASM) and the American Academy of Family their risk for other health problems. The primary Physicians recommend the use of cognitive concern is sleeping medications do not treat behavioral therapy for insomnia (CBT-I) as the underlying sleep disorders such as sleep apnea leading treatment (Qaseem, Kansagara, Forciea, and often exacerbate the problem and daytime & Cooke, 2016). This recommendation is based sleepiness symptoms. on the review of trials from 2004 to 2015 that If clinicians suspect sleep apnea may be con- compared CBT-I treatment to medications with tributing to sleep disturbance, depending on the CBT-I being found to be the more effective and person’s access to medical care, a referral for a safer treatment option. Research has shown that 23 Cultural Considerations and Sleep 327 the use of CBT-I has equal or greater effective- these populations need interventions targeted at ness when compared to medications in the short sleep-related difficulties probably even more than term, but over time CBT-I has been shown to be the general Caucasian population. more effective and have more durable effects (Morin, Colecchi, Stone, Sood, & Brink, 1999). CBT-I goes beyond general sleep hygiene References such as avoiding alcohol, not watching television in bed, etc., and addresses the key behaviors and Adenekan, B., Abhishek, P., Mckenzie, S., Ferdinand, Z., thoughts that can interfere with sleep. Treatment Georges, C., & Girardin, J. (2013). Sleep in America: Role of racial/ethnic differences. Sleep Med Reviews, includes several behavioral interventions of sleep 17, 255–262. restriction, stimulus control, relaxation therapy, Adler, N. E., & Rehkopf, D. H. (2008). US disparities in and cognitive therapy specifically aimed at health: Descriptions, causes, and mechanisms. Annual insomnia. There are few known side effects of Review of Public Health, 29, 235–252. Barilla, H. E., Corbitt, C., Chakravorty, S., Perlid, M., & CBT-I besides the possibility of increasing day- Grandner, M. A. (2013). Are those with more physi- time sleepiness associated with sleep restriction cally demanding jobs more likely to exhibit short/long therapy. But compared to medications, the side sleep duration? Sleep, 36, A325–A326. effects are significantly less and people often no Benuto, L., & O’Donohue, W. (2015). Is culturally sensitive cognitive behavioral therapy an empirically sup- longer need medications following treatment, ported treatment? The case for Hispanics. International thereby eliminating all potential drug side effects. Journal of Psychology and Psychological Therapy, CBT-I can be delivered in an outpatient mental 15(3), 405–421. health setting, but also can be done within primary Billings, M. E., Auckley, D., Benca, R., Foldvary- Schaefer, N., Iber, C., Redline, S., … Vishesh, K. care clinics as well in as few as three to five ses- (2011). Race and residential socioeconomics as pre- sions. Sadly, there are limited qualified clinicians dictors of CPAP adherence. Sleep, 34(12), 1653–1658. trained in CBT-I and even further limitations when Blank, M., Zhang, J., Lamers, F., Taylor, A. D., Hickie, you consider ethnicity and cultural factors in sleep. I. B., & Merikangas, K. R. (2015). Health correlates of insomnia symptoms and comorbid mental disorders in It is very difficult to find a CBT-I therapist in gen- a nationally representative sample of US adolescents. eral yet alone a therapist who can speak various Sleep: Journal of Sleep and Sleep Disorders Research, languages and also aware of cultural factors in 38(2), 197–204. sleep. Further, the research on ethnicity and CBT-I Buxbaum, S. G., Elston, R. C., Tishler, P. V., & Redline, S. (2002). Genetics of the apnea hypopnea index in is very limited. A PsycINFO search using the Caucasians and African Americans: I. Segregation terms insomnia and Hispanic or Latino yielded analysis. Genetic Epidemiology, 22, 243–253. only 52 publications. The majority of those publi- Center for Disease Control and Prevention. (2011). CDC cations was focused on psychotropic medication health disparities and inequalities report United States (p. 2011). Atlanta, GA: CDC. and/or is irrelevant to insomnia among Latinos; Chen, X., Wang, R., Zee, P., Lutsey, P. L., Javaheri, S., none of the manuscripts reviewed discussed the Alcántara, C., … Redline, S. (2015). Racial/ethnic dif- use of CBT-I with Latinos. Nonetheless, there is ferences in sleep disturbances: The Multi-Ethnic Study evidence to suggest that standard CBT generalizes of Atherosclerosis (MESA). Sleep, 38(6), 877–888. Colten, H. R., & Altevogt, B. M. (2006). Sleep disorders to Latinos (Benuto & O’Donohue, 2015) indicat- and sleep deprivation: An unmet public health prob- ing that the active ingredients in CBT-I may gener- lem. Washington, DC: Institute of Medicine: National alize to Latinos and other ethnicities as well. Given Academies Press. Institute of Medicine Committee on the substantial prevalence rates of sleep-related Sleep Medicine and Research. Ford, E. S., Cunningham, T. J., Giles, W. H., & Croft, J. B. difficulties among minority groups, interventions (2015). Trends in insomnia and excessive daytime for treating these difficulties are needed. sleepiness among US adults from 2002 to 2012. Sleep Complexities aside, the literature clearly indicates Medicine, 16(3), 372–378. that insomnia is a highly treatable condition via Gamaldo, A. A., McNeely, J. M., Shah, M. T., Evans, M. K., & Zonderman, A. B. (2015). Racial differences the use of CBT-I. While the research regarding in self reports of short sleep duration in an urban- sleep-related difficulties among various ethnic dwelling environment. The Journals of Gerontology. groups and CBT-I treatment is needed, it is clear Series B, Psychological Sciences and Social Sciences, 70(4), 568–575. 328 R. Gentry

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Weaver, T. E., & Grunstein, R. R. (2008). Adherence to tive sleep apnea: Implications for future interventions. continuous positive airway pressure therapy: The The Indian Journal of Medical Research, 131, 45–258. challenge to effective treatment. Proceedings of the Whinnery, J., Jackson, N., Rattanaumpawan, P., & American Thoracic Society, 5(2), 173–178. Grandner, M. A. (2014). Short and long sleep duration Weaver, T. E., & Sawyer, A. M. (2010). Adherence to con- associated with race/ethnicity, sociodemographics, tinuous positive airway pressure treatment for obstruc- and socioeconomic position. Sleep, 37(3), 601–611. Eating Disorders 24 Kimberly Yu and Marisol Perez

Overview of Eating Disorders ment of AN and BN (Chang, Ivezaj, Downey, Kashima, & Morady, 2008; Hewitt, Flett, & Eating disorders (EDs), which include anorexia Ediger, 1995). In addition, perfectionism has nervosa (AN), bulimia nervosa (BN), and binge been found to strengthen the relationship between eating disorder (BED), are serious psychological, body dissatisfaction and ED pathology (Welch, medical, and public health issues (Smink, van Miller, Ghaderi, & Vaillancourt, 2009). Like Hoeken, & Hoek, 2012). EDs are linked with body dissatisfaction and perfectionism, weight chronic duration and a wide variety of medical stigma is associated with the development of ED complications including bone loss, gastrointesti- pathology (Puhl, Moss-Racusin, & Schwartz, nal issues, and nutritional abnormalities (Mitchell 2012). Weight stigma is defined as negative or & Crow, 2006). EDs are also linked with substan- stigmatizing attitudes toward and discrimination tial psychosocial impairment and comorbid psy- against individuals perceived to carry excess chopathology (Smink et al., 2012). weight or fat (Puhl, Moss-Racusin, Schwartz, & There are a number of risk factors that have Brownell, 2008). Weight stigma is experienced in been associated with the development and main- a variety of domains and often consists of verbal tenance of eating disorders including body dis- bias, such as negative comments, insults, etc. satisfaction, perfectionism, and weight stigma. (Brochu & Morrison, 2007; Puhl et al., 2008). Body dissatisfaction, which is conceptualized as While weight stigma is more commonly experi- negative cognitions, subjective perceptions, and enced by individuals with perceived overweight overevaluation of body shape, size, and weight, is or obesity, research suggests that weight stigma considered central in the development and main- actually occurs across most weight categories tenance of ED pathology (American Psychiatric (Puhl, Peterson, & Luedicke, 2013). Association, 2013; Fairburn, 2008). Notably, Currently, there are a number of established individual perceptions of body image and dissat- evidence-based treatments for EDs. However, isfaction with one’s body have been shown to these evidence-based treatments have been contribute to ED pathology (Perez & Joiner, largely developed for the treatment of EDs in 2003). Similarly, perfectionism has been shown White female populations, and as such, their to be an influential risk factor for the develop- validity and utility with racial/ethnic minorities, males, and LGBT individuals are unknown K. Yu (*) · M. Perez (Smolak & Striegel-Moore, 2001). Nonetheless, Department of Psychology, Arizona State University, for AN there are strong research support for Tempe, AZ, USA family-based therapy (see Bulik, Berkman, e-mail: [email protected]

Brownley, Sedway, & Lohr, 2007; Couturier, ulations affected by EDs, the etiology of EDs has Kimber, & Szatmari, 2013 for a review) and been largely conceptualized using White, middle- modest research support for the use of cognitive to upper-class females (Striegel-Moore & Bulik, behavioral therapy for post-hospitalization 2007). This narrow conceptualization of EDs may relapse prevention (Pike, Walsh, Vitousek, contribute to inaccurate nosology informing cur- Wilson, & Bauer, 2003). For BN, there are strong rent diagnostic guidelines for EDs across diverse research support for cognitive behavioral therapy populations. Additionally, many studies exploring and interpersonal therapy (Hay, Bacaltchuk, prevalence rates of EDs lack sufficient power to Stefano, & Kashyap, 2009; Spielmans et al., accurately detect ED subtypes. Finally, racial/eth- 2013) and modest research support for family- nic minorities in the USA have been shown to based therapy (Le Grange, Crosby, Rathouz, & seek mental health services and treatment less fre- Leventhal, 2007). For BED, there is strong quently than Whites do, which results in biased research support for cognitive behavioral therapy literature dependent upon patient sample demo- and interpersonal therapy (Iacovino, Gredysa, graphics (Kessler et al., 1996). Altman, & Wilfrely, 2012; Wilson, Wilfley, Despite these challenges, however, it is evi- Agras, & Bryson, 2010). dent that ED pathology impacts individuals Historically, ED pathology has been largely across diverse groups and populations (Hudson characterized as culture-bound and conceptual- et al., 2007; Perez & Plasencia, 2017). ized as primarily affecting middle- and upper- Accordingly, this chapter aims to summarize the class Caucasian females in the USA literature across racial/ethnic minorities (e.g., (Striegel-Moore & Bulik, 2007). Among Blacks, Latinx, Asian Americans), males, and Caucasian samples, nationally representative epi- LGBT (i.e., lesbian, gay, bisexual, and transgen- demiological research indicates that lifetime der) individuals and the cultural factors relevant prevalence rates are 0.60% for AN, 1.00% for to each group. BN, and 2.80% for BED in the USA (Hudson, Hiripi, Pope, & Kessler, 2007). However, more recent research indicates that ED pathology Prevalence Rates, Clinical occurs across a wide variety of populations. For Presentation, Risk Factors, example, research shows that EDs occur among and Evidence-Based Treatment racial and ethnic minorities in the USA (Alegria Among Minority Populations et al., 2007; Marques et al., 2011; Taylor, Caldwell, Baser, Faison, & Jackson, 2007), Black Americans among males (Striegel-Moore et al., 2009), LGB (i.e., lesbian, gay, bisexual) individuals (Austin Research on EDs among Black populations in the et al., 2009; Austin, Nelson, Birkett, Calzo, & USA indicates that in general, Blacks exhibit Everett, 2013; Katz-Wise et al., 2015), and trans- lower prevalence rates of AN compared to White gender individuals (Diemer, Grant, Munn- populations (Striegel-Moore et al., 2003; Taylor Chernoff, Patterson, & Duncan, 2015). et al., 2007). Although existing research on BN in Work to assess the prevalence of ED pathology Black populations is mixed when compared to across diverse demographic groups is of great white individuals, BED is the most common ED importance and utility (e.g., Austin et al., 2013; reported in this population (Marques et al., 2011; Schaefer et al., 2018; Striegel-Moore et al., 2009). Striegel-Moore et al., 2003; Taylor et al., 2007). However, there are significant challenges to con- Taylor and colleagues found that the lifetime ducting research on minority populations with prevalence rates for AN are 0.17%, 1.49% for eating disorders. First, eating disorders have lower BN, and 1.66% for BED among Black individu- base rates when compared to other mental disor- als (Taylor et al., 2007). ders such as depression, anxiety, or substance use. Some important differences in the clinical pre- Further, due to stereotyped beliefs regarding pop- sentation of EDs exist among Black populations. 24 Eating Disorders 333

First, while the prevalence of AN among Black body dissatisfaction than White females (Barry populations is low compared to that of Whites, & Grilo, 2002; Wood, Nikel, Petrie, & Trent, the average age of onset of AN among Black 2010). However, some research suggests that individuals is 14 years old (Taylor et al., 2007) differences in body dissatisfaction that exist compared with 15.4 years among Whites between Whites and ethnic/racial minorities are (Striegel-Moore et al., 2003). In regard to BN, much less substantial than historically believed Black individuals present with many similarities and perhaps are decreasing across time (Grabe to Whites, including similar functioning and & Hyde, 2006). Indeed, research has demon- severity; however, the literature has identified strated that once body dissatisfaction is present, some key differences. For example, Black indi- it is associated with eating disorder symptoms viduals with BN have been found to have shorter among Black women (Perez & Joiner, 2003). episode durations (1–7 years) than White indi- Acculturative stress has also been linked viduals (average of 8.3 years, Hudson et al., with ED pathology, particularly among racial/ 2007; Taylor et al., 2007). Among individuals ethnic minority groups (Cachelin, Veisel, seeking treatment for BN, Blacks may have Barzegarnazari, & Striegel-Moore, 2000; Davis higher body mass indexes (BMIs) and higher & Katzman, 1999; Perez, Voelz, Pettit, & Joiner, rates of depression than White individuals (Chui, 2001). Acculturation is defined as the process of Safer, Bryson, Agras, & Wilson, 2007). Finally, adaptation and assimilation of a different cul- Black females with BN may have higher rates of ture to one’s own (Berry, 1998). Consequently, reported sexual abuse but lower rates of sub- acculturative stress is conceptualized as the psy- stance use and self-harm behaviors compared chosocial stress associated with this process. with White females (Dohm et al., 2002). For Acculturative stress may increase risk for EDs BED, overall, research suggests similarities through two distinct pathways. First, accultura- between Black and White individuals in clinical tion is linked with increased exposure to and presentation. These similarities include mental, adoption of Western values, including those physical, and psychosocial functioning, comor- regarding attractiveness (e.g., thin body ideal bidity, ED attitudes, frequency of binge eating and muscular body ideal). Perceived differences episodes, and rates of metabolic syndromes between acculturated body ideals and one’s own (Elliott, Tanofsky-Kraff, & Mirza, 2013; Franko body may lead to increased body dissatisfac- et al., 2012; Udo et al., 2015). However, Blacks tion, an empirically supported risk factor in the with BED may have shorter episode duration development of EDs (Gordon, Castro, Sitnikov, compared with other racial/ethnic groups (Taylor & Holm-Denoma, 2010). Indeed, increased et al., 2007) and are more likely to report stress acculturation has been shown to be associated related to school/work and critical comments with body dissatisfaction and ED pathology about weight, shape, or eating from others as pre- (Davis & Katzman, 1999; Perez et al., 2001). ceding events to disorder onset (Pike et al., 2006). Second, the acculturative process may generate When examining the literature on risk fac- stress. ED behaviors, such as binge eating or tors for eating disorders, both body dissatisfac- restriction, may be used as coping strategies to tion (a universal risk factor for eating disorders) tolerate experienced stress and distress (Perez and acculturative stress (a unique ethnic minor- et al., 2001). Indeed, acculturative stress has ity group risk factor) have some empirical sup- been linked with the development of BN (Perez port. In both the psychological literature and et al., 2001) and general ED symptomatology popular culture, ethnic/racial minorities, espe- among Black women (Gordon et al., 2010). cially females, have been thought to have lower The evidence-based treatment literature for levels of body dissatisfaction compared with Black individuals with EDs is scarce. A random- White females (Grabe & Hyde, 2006). Indeed, ized controlled trial comparing cognitive research suggests that Black females may have behavioral therapy and interpersonal therapy for more positive body image and lower rates of BN included analyses with minority individuals 334 K. Yu and M. Perez

(Chui et al., 2007). Although both effective, CBT Rios, & Hurtado, 2015). In addition to differ- produced lower rates of engagement in binge eat- ences in body ideals, eating is also considered an ing and purging behaviors; thus, the authors sug- important familial bonding experience and food gest that CBT should be the preferred treatment is highly valued. Consequently, Latinx individu- for Black individuals with BN (Chui et al., 2007). als with EDs may experience additional guilt and Among Black women who engage in binge eat- shame in regard to their symptoms. Latinx ing, those with moderate scores had significant females, in particular, who are not only encour- symptom reduction during an intervention aged to celebrate curvaceous figures and con- designed to increase physical activity and healthy sume traditional foods in abundance but who also eating (Mama et al., 2015). However, reductions may feel societal pressures to achieve thinness, in binge eating were not seen among those with may struggle with eating, weight, and shape con- severe scores. cerns in an attempt to concurrently adhere to multicultural pressures and societal standards of beauty (George & Franko, 2010). Latinx Americans Similar to the Black literature, both body dissatisfaction and acculturative stress have some Among Latinx populations, rates of ED pathol- empirical support. The body dissatisfaction liter- ogy have been shown to be roughly similar to ature is mixed with some studies indicating lower those reported by White populations (Alegria levels of body dissatisfaction (Barry & Grilo, et al., 2007). Lifetime prevalence rates of EDs 2002; Franko & Herrera, 1997), while other stud- among Latinx within the USA are 0.08% for AN, ies suggest comparable levels of body dissatis- 1.61% for BN, and 1.92% for BED (Alegria faction between White and Latinas (Cachelin, et al., 2007). Similar to Blacks, BED is the most Rebeck, Chung, & Pelayo, 2002; Shaw, Ramirez, prevalent ED in this group (Marques et al., 2011) Trost, Randall, & Stice, 2004). However, the and Latinx report fewer cases of AN compared examination of body dissatisfaction among with White populations (Alegria et al., 2007). Latinas is complex. Focus groups with Latinas The clinical presentation of EDs among reveal women grapple with the American stan- Latinx has some unique aspects. First, Latinx dards of beauty (i.e., an ultrathin ideal) and with with AN may be less likely than Whites are to cultural ideals of beauty that promote a curvy report fear of gaining weight or body dissatisfac- hourglass figure (Franko et al., 2012). Regardless, tion, leading to a potential underrepresentation of when discrepancies between ideals and body Latinx with AN in epidemiological research shape occur, this is associated with eating disor- (Alegria et al., 2007). In regard to BN and BED, der symptoms (Gordon et al., 2010). obesity, which is a growing issue among some Acculturative stress has been shown to con- Latinx populations (Kuba & Harris, 2001), may tribute to the development of ED pathology serve as a specific trigger for binge eating behav- among racial and ethnic minorities. More specifi- ior among these individuals. Indeed, one study cally, acculturative stress has been linked with found that Latinx individuals with severe obesity the development of BN (Perez et al., 2001) and were four to six times more likely to report an ED general ED symptomatology among Latinx indi- than those without obesity (Alegria et al., 2007). viduals (Cachelin et al., 2000; Gordon et al., Cultural values may also differentially affect 2010). While much of the research addressing the the presentation of EDs among Latinx. For exam- influence of acculturative stress on ED pathology ple, some research suggests that among Latinx has examined this risk factor among females, females, slender but curvaceous figures, collo- acculturative stress has also been linked with quially referred to as “gordibuena” (Perez, Ohrt, body dissatisfaction and endorsement of Western & Hoek, 2015), are idealized in contrast to the media among Latinx males (Warren & Rios, thin female ideal body commonly valued by 2013). Overall, a growing body of research sug- European American females (Romo, Mireles- gests that acculturation is a substantial risk factor 24 Eating Disorders 335 for the development of EDs among racial/ethnic 2004). Epidemiological research has reported minority groups in the USA. lifetime prevalence rates of 0.10% for AN, 1.50% Within the literature, reporting of use of for BN, and 1.24% for BED among Asian evidence-based treatments is starting to occur. Americans, all of which are similar to rates of Both patients and therapists report that the core EDs among Whites (Marques et al., 2011). components of cognitive behavioral therapy The existing literature on the clinical presenta- apply to Latinas for BN and BED. Adaptations tion of EDs among Asian Americans suggests of the treatment include providing additional that EDs may present uniquely in these individu- therapy sessions and psychoeducation with the als. For example, BMI prior to ED onset may be family, particularly if the patient endorses high lower among Asian Americans than among degrees of the family members as referents and Whites (Lee & Lock, 2007). Additionally, some high interdependent values (i.e., belief that the research suggests that subclinical and atypical needs of the group or family are more important EDs are more common among Asian Americans than the need of the individual; Reyes-Rodriguez, than among other racial/ethnic groups (Smart, Baucom, & Bulik, 2014; Shea, Cachelin, & Tsong, Mejia, Hayashino, & Braaten, 2011). Uribe, 2012). Additional adaptations include the Furthermore, Asian Americans may report less structuring of meal plans to include foods con- compensatory behaviors typically associated sistent with the culture and food availability with ED pathology than other populations based on the economic sector of the patient. (Lucero, Hicks, Bramlette, Brassington, & Both therapists and patients report the most Welter, 1992). Instead, Asian Americans may problematic module of cognitive behavioral endorse complaints of bloating and lack of appe- therapy is the body image interventions (Shea tite, as well as more bulimic symptoms than their et al., 2012). The focus on the thin ideal is not as White counterparts (Lee & Lock, 2007). Asian applicable for Latinas who report needing assis- Americans may also report different types of tance with navigating the discrepant ideals of body dissatisfaction, often focusing on facial fea- American culture and the norms of their own tures, arms, breasts, height, or skin tone rather culture. Finally, adaptation to treatment includes than simply body size or weight (Mintz & an emphasis on acculturative stress issues that Kashubeck, 1999). Finally, EDs among Asian occur within the family (Perez, 2017; Shea et al., Americans, in particular, women, may be linked 2012). Binge eating among Latinas can occur with emotional distress. Specifically, EDs have more frequently during family meals than in iso- been conceptualized as a way to express distress lation due to familial pressures to eat (Perez, without violating cultural norms of emotional 2017; Shea et al., 2012). restraint typical in many Asian cultures (Jackson, Keel, & Lee, 2006). Among the risk factor literature, acculturative Asian Americans stress and perfectionism contribute to the development and maintenance of EDs. Acculturative In regard to Asian Americans in the USA, there stress has been shown to be associated with ideal- are currently mixed epidemiological findings on ization of Western beauty norms among Asian the prevalence of EDs. To demonstrate, some Americans (Smart et al., 2011) and general eating studies suggest prevalence rates of ED pathology disorder symptomatology (Gordon et al., 2010). may be lower among Asian Americans than While perfectionism has been shown to predict among other racial and ethnic groups (Regan & ED pathology across a diverse range of racial/eth- Cachelin, 2006; Tsai & Gray, 2000). However, nic groups, cultures, and communities (Hewitt other studies have found similar rates of EDs et al., 1995), in particular, some research suggests among Asian Americans when compared with that perfectionism may occur at high rates among other racial and ethnic populations (Franko, Asian Americans (Wang, 2010). Smart and col- Becker, Thomas, & Herzog, 2007; Shaw et al., leagues partially attribute this disparity to the way 336 K. Yu and M. Perez in which Asian Americans are often portrayed Interestingly, recent evidence suggests that negatively in comparison to the dominant White these rates are likely underestimates (Murray culture in the USA (2011). Asian Americans may et al., 2017). For example, one nationally repre- feel a responsibility to correct negative percep- sentative study found that males accounted for tions of their culture in the USA by working dili- one in four cases of AN and BN (Hudson et al., gently to be “perfect” (Smart et al., 2011). A 2007). Overall, however, research addressing qualitative study of ED-trained therapists with EDs in male populations is substantially lacking, experience treating Asian Americans highlighted with less than 1% of contemporary peer-review intense pressure observed among Asian Americans literature relating specifically to male presenta- to achieve in academics, career, and in appearance tions of AN (Murray, Griffiths, & Mond, 2016). (Smart et al., 2011). Importantly, perfectionism Given these findings, it is no longer reasonable to has been shown to predict EDs in both females assume that EDs among males are uncommon. (Hewitt et al., 1995) and males (Grammas & On the contrary, males make up a substantial Schwartz, 2009) and may be a notable risk factor population of consideration and warrant greater when considering Asian American populations. research and attention. Similar to the other ethnic groups, the treat- In considering EDs among male populations, ment literature with Asian Americans is scant. In there are some notable differences of consider- one case study adapting cognitive behavioral ther- ation. First, research generally suggests that, com- apy (Fairburn, 2008) for an Asian American pared with females, EDs among males are more women, the core concepts of the treatment were likely to present as comorbid with other psychiat- maintained (Smart, 2010). Additional therapy ses- ric disorders (e.g., substance use, psychotic symp- sions were offered to include the family. In these toms; Carlat, Camargo, & Herzog, 1997; sessions, treatment targets were issues of stigma, Striegel-Moore, Garvin, Dohm, & Rosenheck, shame, and hierarchy of the family system. 1999). Compared with females, EDs in males are Acculturative stress as it relates to gender roles, also more likely to present at a later age of onset perfectionism, self-esteem, and interpersonal and are more commonly reported in later adoles- relationships was also targeted (Smart, 2010). The cence (Guegen et al., 2012; Mitchison & Mond, therapist highlights using an empathic but author- 2015). In considering AN, BN, and BED, research itative approach to the therapeutic relationship. suggests males may exhibit different symptomatology compared with females. For example, males with AN have been found to be oriented Males toward achieving leanness and improving muscu- lature, rather than thinness (Murray et al., 2017). Historically, EDs among males have been per- Males with BN may be less likely than females ceived as rare (Murray et al., 2017). Notably, are to engage in laxative use or vomiting, but may however, EDs have been reported in males for as be more likely to engage in non-purging compen- long as they have been reported in females satory behaviors such as extreme dietary restric- (Murray et al., 2017). Indeed, recent research tion and excessive exercise (Striegel-Moore et al., suggests that while females exhibit higher rates 2009). Finally, males with BED may be less likely of EDs than males do, a substantial portion of the to report experiencing loss of control during US male population will suffer from a clinically binges than females are (Lewinsohn, Seeley, significant ED in their lifetime (Wade, Keski- Moerk, & Striegel-Moore, 2002). Rahkonen, & Hudson, 2011) and males are an Males may also be more likely than females important population of consideration in the ED are to demonstrate muscle dysmorphia, which is field. Overall, prevalence rates for EDs among understood as a fear around being insufficiently males have been shown to be 0.30% for AN, muscular as well as an overwhelming desire for 0.50% for BN, and 2.00% for BED (Hoek, 2006; muscularity (Pope, Phillips, & Olivardia, 2000). Hudson et al., 2007). Muscle dysmorphia is linked with the muscular 24 Eating Disorders 337 male body ideal popular in Western culture (Pope changes in perceived deviation from male body et al., 2000). The muscular male body ideal is ideals throughout the life course. characterized by a high degree of upper body Weight stigma is a particularly salient predic- muscularity and a low degree of body fat tor of ED pathology among males. Research indi- (McCreary & Sasse, 2000). Muscle dysmorphia cates that males with EDs are more likely than can elicit muscularity-oriented disordered eating, females are to have a previous history of over- characterized by distinct eating periods oriented weight or obesity (Andersen, 1999; Strother, toward gaining muscle and cutting body fat. These Lemberg, Stanford, & Turberville, 2012). behaviors are also associated with the overregula- Additionally, males with EDs are also more tion of protein consumption and dietary restric- likely to have experienced weight-related teasing tion to build muscle and achieve a caloric deficit, than females with EDs (Carlat et al., 1997; respectively (Griffiths, Murray, & Touyz, 2013). Guegen et al., 2012). As such, a history of over- Muscle dysmorphia is also linked with excessive weight or obesity, weight stigma, weight-based exercise and use of supplements and anabolic ste- teasing, or weight-related bullying is of notewor- roids (Calzo et al., 2015; Labre, 2002). thy consideration in addressing EDs, especially Less research exists addressing body dissatis- EDs in male populations. faction among males than among females As previously discussed, clinicians working (McCabe & Ricciardelli, 2004). In general, with male clients should recognize that EBTs for research indicates that females report higher lev- EDs have largely been developed with female els of body dissatisfaction than do males populations. As such, EBTs for EDs may differ in (Tiggemann & Pennington, 1990). However, it is their utility and relevance in male populations likely that comparing body dissatisfaction (Smolak & Striegel-Moore, 2001). Clinicians between males and females is more nuanced. and readers should also take into account the Some studies have found similar levels of body ways in which current ED diagnostic frameworks dissatisfaction between males and females may affect and impact accurate diagnoses of EDs (Silberstein, Striegel-Moore, Timko, & Rodin, among males (Murray et al., 2017). Finally, as 1988). Furthermore, another research suggests EDs have been stereotypically considered a that while males and females may not differ sub- “female” problem both in psychological practice stantially in degree of body dissatisfaction, direc- and within popular culture, stigma has been tionality and nature of body dissatisfaction may shown to be a problematic barrier among males vary between males and females. In other words, with EDs (Murray et al., 2017). Shame and stig- males may be more likely to desire to be heavier matization associated with conceptions of com- or more muscular, whereas females are more promised masculinity may result in prolonged likely to desire to be thinner (Silbertstein et al., illness duration and negative treatment outcomes 1988). Indeed, males are more likely to adhere to (Murray et al., 2017). In working with males with muscular body ideals and may exhibit body dis- EDs, clinicians are encouraged to educate male satisfaction through the use of excessive exercise, clients about myths and misconceptions regard- supplements, anabolic steroids, as well as ing populations affected by EDs to reduce feel- muscularity-oriented disordered eating (Calzo ings of shame and improve treatment outcomes. et al., 2015; Labre, 2002). Among males, it also seems that these behaviors may evolve over time as well as over the life course. More specifically, Lesbian, Gay, Bisexual, during adolescence and young adulthood, males and Transgender Individuals may be equally divided between wanting to lose weight and wanting to gain weight. However, in LGB (i.e., lesbian, gay, bisexual) individuals are older adulthood, adult males report a stronger another population of consideration in the ED desire to lose weight (McCabe & Ricciardelli, field. Importantly, LGB individuals as a group 2004). These differences may be attributed to may exhibit rates of ED pathology greater than or 338 K. Yu and M. Perez at least comparable to those of heterosexuals Research on the clinical presentation of EDs (Austin et al., 2013; Diemer et al., 2015). Within among LGB individuals highlights that ED specific sexual minority groups, different rates of behavior may differ among sexual minority ED pathology may exist. For example, research group. For example, in one study, LGB individu- suggests that gay males report greater incidence als demonstrated higher rates of binge eating of ED pathology and attitudes compared with than their heterosexual counterparts did (Austin heterosexual males (Williamson & Hartley, 1998; et al., 2013). Bisexual individuals may also be Yager, Kurtzman, Landsverk, & Wiesmeier, more likely to report purging than gay, lesbian, 1988) and, in some cases, heterosexual and les- and heterosexual individuals (Austin et al., 2009; bian females (Yelland & Tiggemann, 2003). Robin et al., 2002). Among females, findings are mixed with some In regard to transgender populations, little studies indicating that lesbian and bisexual research currently exists examining the clinical females report lower (Moore & Keel, 2003), sim- presentation of EDs among transgender individu- ilar (Davids & Green, 2011), and higher rates of als. However, the literature suggests that body dis- ED pathology compared with heterosexual satisfaction may be an especially salient predictor females (Diemer et al., 2015). of ED pathology among these individuals. Body ED pathology has also been shown to affect dissatisfaction among transgender individuals transgender individuals (Guss, Williams, Reisner, may be linked with gender dysphoria and can be Austin, & Katz-Wise, 2017). Transgender indi- experienced in relation to specific body parts, viduals identify with a gender different from their especially body parts that do not align with gen- sex assigned at birth, whereas cisgender individ- der identity (e.g., breasts, body hair, stomach, uals identify with a gender that is concordant hips, etc.; American Psychiatric Association, with their sex assigned at birth (Guss et al., 2017). 2013; Cuzzolaro, Vetrone, Marano, & Garfinkel, Recent research suggests that transgender indi- 2006). EDs among transgender individuals may viduals may be particularly susceptible to devel- be linked to a desire to suppress unwanted body oping ED pathology due to high rates of body features and accentuate features of one’s identi- dissatisfaction and distress associated with gen- fied gender (Algars, Alanko, Santtila, & der dysphoria, which is conceptualized as con- Sandnabba, 2012). Indeed, some research has flict between an individual’s assigned gender and shown that transgender individuals with EDs the gender with which they identify (American often describe a desire to change their bodies in an Psychiatric Association, 2013; Witcomb et al., attempt to suppress features associated with their 2014). Research on prevalence rates of EDs biological sex (e.g., muscularity) or accentuate among transgender individuals is lacking; how- features of one’s identified gender (e.g., thinness ever, extant research suggests that transgender associated with feminine ideals; Algars et al., individuals have much higher rates of EDs than 2012). Additionally, transgender individuals are cisgender individuals do. To illustrate, one study more likely to report fasting, using diet pills, and of nearly 290,000 students from universities taking laxatives to lose weight than their cisgen- across the USA found that transgender young der counterparts are (Guss et al., 2017). adults had two times greater odds of a past-year Research addressing body dissatisfaction diagnosis of AN or BN compared with cisgender among LGBT individuals has yielded interesting females (Diemer et al., 2015). Additionally, the findings. Generally, research suggests that gay same study found that transgender young adults males report more body dissatisfaction than their were over twice as likely to report using diet heterosexual counterparts do (Beren, Hayden, pills, laxative, or vomiting compared with cis- Wilfley, & Grilo, 1996; Morrison, Morrison, & gender females (Diemer et al., 2015). Given these Sager, 2004). However, among females, findings findings, it is evident that LGBT individuals are mixed (Beren et al., 1996; Morrison et al., make up a notable population of consideration in 2004). It seems that, overall, sexual orientation ED research and clinical practice. may be more influential in predicting body dissat- 24 Eating Disorders 339 isfaction among males than among females Lewis, 2015). Among males, minority stress has (Morrison et al., 2004). It has been suggested that been linked with body dissatisfaction and ED gay culture’s presumed emphasis and focus on symptomatology (Kimmel & Mahalik, 2005). physical appearance may elicit increased body dis- Among transgender individuals, the role of satisfaction among gay males (Beren et al., 1996; minority stress in the development and perpetua- Yelland & Tiggemann, 2003). On the other hand, tion of EDs is less established; however, minority due to normative sociocultural pressures affecting stress likely plays a similar role (Watson, Veale, females, discontent and scrutiny with one’s body & Saewyc, 2016). Indeed, transgender individu- are a normative experience for heterosexual, les- als have been found to be nearly five times as bian, and bisexual females (Cogan, 1999). likely to report an ED diagnosis compared with Among transgender individuals, body dissat- cisgender females (Diemer et al., 2015). Notably, isfaction is common source of substantial distress social connectedness and support have been (Cuzzolaro et al., 2006; Jones, Haycraft, Murjan, linked with lower odds of ED pathology among & Arcelus, 2016) and may contribute to height- transgender individuals (Watson et al., 2016). ened risk of developing EDs compared to the In implementing EBTs in work with LGB cli- general population. As gender dysphoria is linked ents, readers and clinicians are encouraged to with body dissatisfaction, it follows that trans- review the American Psychological Association gender individuals may experience greater dis- practice guidelines for work with lesbian, gay, tress associated with their physical appearance. and bisexual clients (American Psychological Transgender individuals may specifically feel Association, 2012). Clinicians should recognize distressed about body parts that do not align with that while LGB individuals make up several their identified gender (e.g., breasts, penis, body groups of sexual minorities, sexual orientation is hair, stomach, hips, etc.; Cuzzolaro et al., 2006; often conceptualized along a spectrum and sex- Witcomb et al., 2014). ual minority clients may not identify as belong- Another notable risk factor in considering ED ing to a specific sexual orientation or category. pathology is minority stress. Minority stress the- Clinicians should recognize that LGB clients are ory postulates that LGBT individuals are at at heightened risk of social stressors and stigma- increased risk for physical and mental health tization (Meyer, 2003) which may impact prac- problems, including EDs, as a result of social tice and application of EBTs as well as treatment stress, stigma, and discrimination targeting their outcomes. minority status (Meyer, 2003). This psychosocial In adapting EBTs for work with transgender stress may be attributed to lack of social accep- individuals, clinicians are encouraged to refer to tance, expectation of prejudice, perpetration of the American Psychological Association guide- harassment, and even physical violence (Berlan, lines on psychological practice with transgender Corliss, Field, Goodman, & Austin, 2010; Coker, and gender nonconforming individuals (American Austin, & Schuster, 2010). Psychological Association, 2015). Clinicians Research has shown that, among LGB individ- should recognize that mental health problems, uals, minority stress has been linked with ED including EDs, experienced by transgender indi- symptomatology (Brewster et al., 2014; Watson, viduals may be related to gender-related concerns Grotewiel, Farrell, Marshik, & Schneider, 2015; or gender dysphoria or may be indirectly influ- Wiseman & Moradi, 2010). It is possible that LGB enced by way of minority stressors (Meyer, 2003). individuals may use maladaptive coping behav- However, mental health problems in this popula- iors, such as binge eating or restriction, to deal tion may also be unrelated to gender identity or with minority stressors (Katz-Wise et al., 2015). gender-related concerns. Within the last two These findings have been shown to occur among decades, there has been a substantial increase in both males and females. For example, minority research and knowledge about this community, stress has been linked with increased binge eating and guidelines and recommendations for gender- among lesbian and bisexual females (Mason & affirming care are updated frequently. 340 K. Yu and M. Perez

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Rory T. Newlands, Janet Brito, and Dominic M. Denning

Human sexuality is a multifaceted process reliant Culture embodies group behaviors, beliefs, on the integration and cooperation of the neuro- values, and traditions, which in turn shape indi- logical, endocrine, and vascular systems viduals behaviors, attitudes, emotions, and val- (Bachman & Philips, 1998) and the individual’s ues, particularly those surrounding sexuality psychological health (Althof et al., 2005), which (Ahmed & Bhugra, 2007). Cultures have the in turn is impacted by the larger cultural frame- potential to moderate or mediate the develop- work in which the individual operates (Kadri, ment of sexual dysfunctions, with some cultural Alami, & Tahiri, 2002). Sexual health plays a values serving as protective factors and others vital and bidirectional role in individuals’ psy- as risk factors (Ahmed & Bhugra, 2007). chological health and quality of life (Althof et al., Additionally, culture appears to impact those 2005; Laumann, Paik, & Rosen, 1999). The defi- who seek treatment and whether they complete nition of sexual dysfunction, or the interferences treatment. For instance, 10–30% of Americans of the sexual response cycle, was expanded in the experiencing sexual dysfunction receive treat- DSM-V to include duration and frequency ment (Shifren et al., 2009), whereas an esti- (Sungur & Gündüz, 2014), but in general it mated 2% of Koreans discuss their sexual occurs when an individual or couple experiences concerns with a healthcare provider (Moreira interpersonal distress resulting from not being Jr., Kim, Glasser, & Gingell, 2006). Further, able to enjoy sexual activities, even though they non-white couples are exceedingly more likely desire to (Avasthi, Grover, & Sathyanarayana to drop out of treatment (71% vs. 17%, respec- Rao, 2017). Sexual dysfunction is one of the tively) than their white counterparts (Bhui, most common sexual disorders and is estimated 1998). This is unsurprising, given that culture to impact up to 46% of individuals (Simons & impacts how individuals conceptualize, experi- Carey, 2001). However, prevalence rates can ence, express, and cope with psychological dis- range dramatically when culture and the types of tress (American Psychiatric Association, 2013) disorders are taken into account (Ahmed & and that culture plays such a fundamental role in Bhugra, 2007). formation of sexual scripts, which dictate what behaviors are sexual “normative,” “dysfunc- R. T. Newlands (*) · D. M. Denning tional,” and “deviant” (Ahmed & Bhugra, University of Nevada-Reno, Reno, NV, USA 2007). Further, culture will shape how individu- J. Brito als explain the origins/causes of their sexual Center for Sexual and Reproductive Health, problems. Honolulu, HI, USA

Overview of Sexual Dysfunction Disorder Diagnostic criteria Premature Persistent or recurrent pattern of To classify a sexual health dysfunction is helpful ejaculation ejaculation during partnered sexual (PE) activity within 1 min following for assessment and treatment. An individual’s or vaginal penetration or before the couple’s level of arousal, desire, satisfaction, and individual wishes it to. The symptoms ability to have an orgasm are some areas where cause significant distress and are not challenges may emerge, resulting in it being due to a nonsexual mental disorder or medical condition or because of labeled a sexual dysfunction. Each condition medication or substance use requires symptom duration of at least 6 months Female Difficulty experiencing orgasm and/ and that symptoms occur during 75–100% of the orgasmic or markedly reduced intensity of time (American Psychiatric Association, 2013). disorder orgasmic sensations, or absence of According to the National Health and Social Life (FOD) orgasms, almost all the time, in all sexual contexts. The symptoms must Survey, the overall prevalence of sexual dysfunc- cause clinical distress or social, tion in the USA was 43% for women and 31% for occupational, or personal impairment, men (Laumann et al., 1999). Below is an over- such as sleep problems or marital view of the sexual dysfunctions, as outlined in problems. Clinicians must determine if it is lifelong versus acquired; the DSM-V. generalized versus situational or never; and mild, moderate, or severe. Disorder Diagnostic criteria The symptoms must not be related to severe distress and a nonsexual Delayed Inability, delay, or infrequent ability mental or medical disorders or due to ejaculation to climax during partnered sexual medication or substance use (DE) activity, resulting in distress for the individual. The symptoms must not Female The individual experiences three of be attributed to a mental health sexual the following six symptoms: (1) an problem, medications that causes DE, interest/ absence or reduced interest in sexual or relational or interpersonal arousal activities, (2) absent or reduced stressors. DE could be lifelong, disorder thoughts or sexual fantasies, (3) acquired, generalized, or situational (FSIAD) disinclined interest to initiate sexual as well as mild, moderate, or severe encounters and lack of sexual responsiveness to partner’s initiations, Erectile Inability to obtain or maintain an (4) no sense of pleasure during sexual disorder (ED) erection while being sexually active acts, (5) absent or low sexual interest or until the end of sexual activity. A to internal or external cues, and (6) decrease in erectile rigidity may also absent or low bodily sensations in occur. To assess accurately, it must be response to sexual activity. To assess determined whether it is situational or accurately, it must cause clinical generalized and mild, moderate, or distress, or social, occupational, or severe and causes distress personal impairment, such as sleep Male Persistently experiencing low sexual problems or marital problems, but it hypoactive desire for sexual activity and no must not be due to domestic violence, sexual desire sexual or erotic thoughts and substance abuse, medications, or a disorder fantasies. The individual must medical condition. Additionally it (MHSDD) experience distress as a result of the must be determined whether it is MHSDD, and the symptoms are not lifelong, acquired, generalized, or related to a nonsexual mental health situational as well as mild, moderate, disorder, relational or interpersonal or severe stressors, medications, and medical conditions or due to substance use 25 Cultural Considerations in the Treatment of Sexual Dysfunction 347

Disorder Diagnostic criteria comes to determining sexual dysfunctions across Genito-pelvic One or more of these symptoms must cultures, it is imperative not to generalize, but to pain/ be present: (1) persistent difficulty understand that the prevalence of sexual dysfunc- penetration having vaginal intercourse; (2) pain disorder in the genital or pelvic area during tions are formed by cultural traditions, rituals, and (GPPD) vaginal intercourse or attempts at doctrines. Bhavsar and Bhugra (2013) stated, “The penetration; (3) significant fear or concepts of culture, sex, dysfunction and diagno- anxiety associated with the pain of sis are all interrelated. Culture plays a role in intercourse, and this fear may be present before, during, or after defining what is abnormal, what is called abnor- vaginal penetration; and (4) attempts mal and the underlying cultural patterns” (p. 146). at vaginal penetration result in a Despite the lack of culturally specific measures tensing or tightening of the pelvic and studies, there are some prevalence studies that floor. It is important to determine if it is lifelong vs. acquired or mild, exist and other data sources that specifically moderate, or severe. Like the other address how common sexual dysfunctions present sexual dysfunctions, symptoms must themselves in various cultures. Below is a litera- cause significant distress, and the ture review conducted on Ebsco. The search pain is not due to substance abuse, a medical or mental health disorder, or involved the words “sexual dysfunction, preva- relational distress lence, cultural” as well as “Latinos and sexual dys- Substance-/ This type of sexual disorder can function,” “Asians and sexual dysfunction,” etc. medication- affect both men and women. It is induced associated with disturbances in sexual Latinx A literature review of sexual dysfunc- sexual function temporally related to dysfunction substance intoxication, withdrawal, or tion among Latinos found that both men and exposure to medications. It may also women with poorly controlled diabetes met the cause inhibited orgasm and criteria for sexual dysfunction with more females diminished sexual desire and reporting low levels of sexual desire and arousal, excitement compared to men (Kenya et al., 2014). This find- American Psychiatric Association (2013) ing correlated with prior research that found higher levels of sexual dysfunction with people diagnosed with diabetes. The men in this study Cross-Cultural Prevalence of Sexual reported high levels of sexual desire. The Dysfunction researchers attributed this finding to culture norms that deem men to be more virile than The data on the prevalence of sexual dysfunction women. Research has also found a sexual dys- across individuals in different cultures is minimal. function prevalence rate of 75.6% among Latina Undoubtedly, cultural beliefs will determine women of low socioeconomic status (SES) whether a sexual problem is deemed a dysfunction (Schnatz, Whitehurst, & O’Sullivan, 2010). The as well as whether an individual will seek help majority of the women reported decreased sex- (Bhavsar & Bhugra, 2013). Davis (1998) states ual desire, dyspareunia, and vaginal dryness. that in Western society, sexuality tends to follow a These findings were similar to other studies that rhythmic pattern that leads to orgasm and is inde- found that postmenopausal women report a pendent of class or culture. This belief, Davis cau- higher prevalence of female sexual dysfunction tions, could lead to negative stereotyping of (FSD), as well as women with low SES cultural sexual norms that are not orderly. (Laumann et al., 1999). Therefore, it is important to explore and understand the unique patterns that each cultural group Asians A meta-analysis by Cheng, Ng, Chen, will embody in clinical practice and stay away and Ko (2007) found prevalence rates of erec- from assuming that a sexual dysfunctional pattern tile dysfunction (ED) to be between 2% and applies to all cultural groups. Overall, when it 81.8%. The authors emphasized the importance 348 R. T. Newlands et al. of considering age, given that ED increases noted in the extant literature, including loss of with age, and also suggested the development semen syndrome, ascetic syndrome, Koro syn- of a universal instrument to assess ED. Among drome, Shenkui syndrome, and Supernatural 19- to 49-year-old women in Hong Kong, FSD impotence (Ahmed & Bhugra, 2007; Wen & was less common compared to same age US Wang, 1980). However, the concept of “cultural- women. Those that reported FSD also reported bound syndromes” and cultural concepts of dis- marital problems, a male partner with ED or tress have been criticized as lacking diagnostic premature ejaculation (PE), and did not con- validity (Bhugra, Sumathipala, & Siribaddana, sider sex as important in their marriage (Zhang 2007). Additionally, as posited by Ventriglio, & Yip, 2012). Compared to Chinese women, Ayonrinde, and Bhugra (2016), given the expo- Japanese women have been found to be more nential increase in globalization and intercon- likely to be motivated to have sex to please their nectedness, via the Internet and social media, old partners (Cain et al., 2003). Kameya (2001) cultural demarcations have become more diffuse. states that these findings relate to Japanese Yet, clinicians and researchers working with sex- women not equating low sexual desire as dis- ual dysfunction should be aware of various cul- tressing. Comparatively, Asian gay men tural beliefs around sexual dysfunction. reported more frequent PE and lack of sexual desire (Lau, Kim, & Tsui, 2006). Dhat Syndrome Dhat syndrome involves intense anxiety and fear over loss of semen dur- Africans In Ghana, one study found that 66% of ing nocturnal emissions. This belief can culmi- men (n = 300) reported sexual dysfunction, such nate into somatic symptoms, such as fatigue, as PE, sexual dissatisfaction, ED, nonsensuality, weakness, guilt, and sexual dysfunction noncommunication, and avoidance. For these (Malhotra & Wig, 1975; Ventriglio et al., 2016). men, sexual dysfunction was correlated with age This syndrome was first noted by westerns in (Amidu et al., 2010). Like men in other countries northern India (Wig, 1960), but its origins date (Althof, 2006; Farvid & Braun, 2006), African back thousands of years to ancient Ayurvedic men are also focused on sexual performance, and texts, which state that semen is produced through using intravaginal ejaculatory latency, as well as a lengthy process making it a precious fluid relying on pornography to determine their ade- (Bhugra & Buchanan, 1989). While this syn- quacy. The authors hope that their findings could drome is still common in the Indian subconti- create more realistic expectations about what is nent, with 64% of men presenting to psychiatric normal sexual functioning. Prevalence of female clinics in India concerned with this issue sexual dysfunction was also high for Ghanaian (American Psychiatric Association, 2013), simi- females. According to Amidu et al. (2010), the lar beliefs were once held in other nations such overall prevalence is 72.8%, with the highest as the USA and Great Britain (Ventriglio et al., concern being anorgasmia, followed by sexual 2016). This syndrome is most common among infrequency, dissatisfaction, and vaginismus. men from lower socioeconomic backgrounds with low educational achievements (American Psychiatric Association, 2013; Khan, 2005), Culturally Bound Syndromes which may be the result of the lack of exposure and Sexual Dysfunction to sex education.

The DSM-5 includes nine cultural concepts of Loss of Semen Syndrome This syndrome mir- distress (formerly known as culturally bound rors Dhat syndrome in many ways, i.e., it involves syndromes). One of the nine (Dhat syndrome) distress over loss of semen via sex, masturbation, pertains to sexual dysfunction. Other cultural or nocturnal emissions and may result in anxiety, conceptions of sexual dysfunction have been somatic symptoms, and/or sexual dysfunction or 25 Cultural Considerations in the Treatment of Sexual Dysfunction 349 issues, such as premature ejaculation, sexual anxi- Shenkui Syndrome Like Dhat syndrome, loss ety, erectile dysfunction, and avoidance of sex/ of semen syndrome, and ascetic syndrome, marriage (Ahmed & Bhugra, 2007). While the Shenkui syndrome is the belief that loss of semen DSM-5 does not make distinctions between loss (primarily though masturbation) will result in of semen syndrome and Dhat, others have (Ahmed energy and kidney deficits (Wen & Wang, 1980). & Bhugra, 2007). This syndrome is most com- This belief is likely rooted in Taoist doctrine, mon in Southeast Asia, particularly Sri Lanka which promulgates the belief that semen is a pre- (Ahmed & Bhugra, 2007). As with Dhat, similar cious fluid and avoiding ejaculation contributes concerns over loss of semen have been reported in to well-being, longevity, and possible immortal- other cultures as well (Ventriglio et al., 2016). ity; thus ejaculation should be saved for procreation (So & Cheung, 2005). Ascetic Syndrome Ascetic syndrome has been described as morbid distress regarding the ana- Supernatural Impotence Supernatural impo- tomic and moral domains of sexuality, resulting tence has been documented among various in social withdrawal, weight loss, and extreme Semitic traditions (Ahmed & Bhugra, 2007). restriction of sexual behaviors (Ahmed & Bhugra, As the name suggests, this is the belief that a 2007). This syndrome is found in India (Ahmed supernatural being (e.g., ghosts) curses an indi- & Bhugra, 2007) and is likely related to the con- vidual with impotence (Ahmed & Bhugra, cept of Dhat. 2007).

Koro Syndrome Koro syndrome is the belief that one’s penis is withdrawing into their abdo- Cultural Considerations men and that this will inevitably kill the suf- ferer (Jilek & Jilek-Aall, 1985). This syndrome As noted above, prevalence rates across cultural has been noted to occur in, Chinese cultures, groups vary, making it difficult to fully design Thailand, Indonesia, and India (Ahmed & research studies that relay what cultural factors Bhugra, 2007; Jilek & Jilek-Aall, 1985). Koro are the most relevant when treating sexual dys- too appears to be related to the concept of functions. Therefore, due to there being a lack of Dhat/loss of semen syndrome, as it has been evidence-based treatments when it comes to pro- attributed to semen loss (Ahmed & Bhugra, viding culturally specific interventions for sexual 2007). However, as noted by early scholars dysfunctions, it is imperative to adopt a cultural studying the phenomenon, the syndrome humility lens and avoid making cultural general- occurs in individuals from various sociocul- izations (Rosen, McCall, & Goodkind, 2017). tural and religious backgrounds and may be Instead of assuming that one set of guidelines rooted in anxiety disorders as it typically applies to all, it is best to ask questions, explore develops after a stressful experience (Jilek & expectations, and inquire on how each individual Jilek-Aall, 1985). Similar beliefs have also defines their own racial and/or ethnic identity and been observed in western populations, but in how it shapes their definition of their sexual western populations such beliefs have been health concern. It is important to understand the associated with psychosis (Jilek & Jilek-Aall, traditions, norms, customs, and values of each 1985). Jilek and Jilek-Aall (1985) argued that cultural group and seek to explore how they can given the syndromes cross-cultural appearance be integrated into establishing rapport with cli- and the fact that “outbreaks” of the syndrome ents and in creating treatment plans that address often occur after large cultural shifts or cul- their sexual health concerns (Bhavsar & Bhugra, tural integration, Koro is a reaction to ethnic, 2013). Moreover, it is necessary for clinicians to socioeconomic, cultural, and biological sur- adopt a cultural lens when evaluating their cli- vival threats. ents’ sexual health concerns (Atallah et al., 350 R. T. Newlands et al.

2016), while also respecting the autonomy of the Exposure to Sexual Education Lack of sex- individual they are treating. ual education and knowledge about sexual physiology is a common trend among those

Cultural Values About Sex and Procreation In experiencing sexual dysfunction and is a key Latinx culture, the values of machismo, component of sex therapy (Beck, 1995). familismo, and marianismo strongly shape views Rawson and Liamputtong (2010) explored the around sexuality (Ingoldsby, 1991) and may impact of culture on exposure to sex education inhibit Latinxs from seeking help or educating among 18- to 25-year-old Vietnamese women. themselves about their sexual health concerns In their qualitative study, they found three (Deardorff, Tschann, Flores, & Ozer, 2010), as themes, (1) the women accepted the cultural well as experiencing an inner conflict about sex- norm that their parents would be silent about ual pleasure due to feeling pressured to abide to providing sex education, (2) the women sexual morality (Hussain, Leija, Lewis, & accepted they would need to explore other Sanchez, 2015). Davila (2005) also argued that sources, and (3) the women needed culturally Latinx cultural norms discourage Latina women specific approaches and interventions. Despite from having sexual knowledge and having access the women wanting sex education, they to sexual health information, predominantly accepted that their culture norms limited expo- because of cultural taboos surrounding females sure, prompting them to obtain their sex educa- talking about sex. From a cultural perspective, tion from their peers and from the media. The sexual shame or lack of knowledge may strongly participants emphasized the necessity of devel- influence whether Latinas seek help for their sex- oping culturally appropriate education that is ual health concerns. With marianismo, or the accessible and that it be provided by someone belief that women’s role is to embody the Virgin who is aware of culture and gender differences. Mary, Latinxs may come to believe that sex is for They stated that it was not necessary that the procreation, and less about pleasure, especially educator be Vietnamese. for women, as men are typically known to be seen as more virile due to machismo (Gil & Acculturation Smokowski, Rose, and Vazquez, 1996). Gil and Vazquez (1996) said the Bacallao (2008) stated that the degree of identi- culture reminds women that “sex is for making fication and endorsement of traditional values babies, not for pleasure” (p. 6). depends on the level of acculturation and generational status of the individual. For instance,

Religion An important factor that may influ- older and immigrant Latinxs may subscribe to ence the sexual health seeking behaviors is reli- the traditional cultural norms with more fre- gion. One’s religious beliefs will impact whether quency than younger Latinx (Buriel, 1993). a person with a sexual health dysfunction will One study found low levels of acculturation seek treatment. In Islamic tradition, for instance, with intrinsic religiosity served as protective talking to someone else about your sexual chal- factors when it came to reducing high risk sex- lenges is taboo, as well as having sex outside of ual behavior among young adult Latinas, while marriage or outside of a heterosexual composi- those that held higher levels of acculturation tion (Sungur & Bez, 2016). For some Islamic while practicing extrinsic religiosity had a and non-Islamic individuals, these cultural fac- increased risk of sexual behavior, possible tors will not impact them and cause sexual dys- related to churches promoting abstinence based function, while for others it may. Sungur and messages (Smith, 2015). Bez (2016) recommend that providers be aware of the cultural factors and focus on providing Cultural Practices Various cultural practices treatments that are more person-centered than may have direct or distal impacts on sexual generalized. functioning. 25 Cultural Considerations in the Treatment of Sexual Dysfunction 351

Female Circumcision Okomo, Ogugbue, Treatment for Specific Disorders Unfor- Inyang, and Meremikwu (2017) found that tunately there is a lack of empirically supported women who have undergone female circumcision treatments for sexual dysfunction (Heiman, are missing treatment-specific interventions and 2002), with treatments for female sexual dys- would benefit from therapies that reduce sexual function demonstrating less empirical support dysfunction-related anxiety and help them to (Frühauf, Gerger, Schmidt, Munder, & Barth, address sociocultural, religious, emotional, and 2013). Additionally, there are considerable dif- physical concerns they may have. As far as preva- ferences in treatment-seeking and treatment com- lence rates, the most common sexual dysfunctions pletion/success rate depending on the type of reported by women who have undergone female disorder as well as the individuals’ cultural circumcision are dyspareunia, low sexual desire, background. and poor sexual satisfaction (Yassin, Idris, & Ali, 2018). The authors recommend educational cam- Male Hypoactive Sexual Desire Disorder paigns to end female circumcision. Similarly, (MHSDD) Many disorders, such as erectile Esho et al. (2017) reported that women experi- dysfunction or delayed ejaculation, present sec- enced problems with desire, arousal, and sexual ondary or comorbid sexual dysfunction to satisfaction. They promote the development of MHSDD due to inability to perform in sexual strategies to manage the complications that arise contexts (Rosen, 2000). The prevalence of from female circumcision, in order to protect MHSDD is around 15% and can result from a women’s sexual right to pleasure. variety of physiological and psychological causes (Rosen, 2000; O’Donohue, Swingen, Dopke, & Regev, 1999). Risk factors for devel- Treatment and Assessment opment of MHSDD include low level of education, consuming antidepressants (SSRIs) or Cultural Considerations in the Assessment of antihypertensive drugs (Rosen, 2000; Sexual Dysfunction As with assessments of Meuleman & Van Lankveld, 2005), older age any psychological disorder, it is key that the clini- (50+ y/o), marital status, history of psychiatric cian gain a firm understanding of the client’s pre- condition/symptoms, and daily alcohol con- senting problem. However, unlike many other sumption (Brotto, Yule, & Gorzalka, 2015; disorders, both the provider and the client(s) may Meuleman & Van Lankveld, 2005). Exact prev- be reticent to bring up sexual problems alence rates are difficult to establish due to the (Montgomery, 2008; Shah, Whitmore, Veselis, frequent misdiagnosis of MHSDD as erectile Dawson, & Rinko, 2017); thus the true present- dysfunction (Meuleman & Van Lankveld, ing problem may be masked by other concerns 2005). Because of these deficits in identifica- such as relationship problems, fatigue, etc. The tion of MHSDD, more reliable methods are clinician performing the assessment needs to needed to assess sexual desire disorders strike a balance between demonstrating an open- (Meuleman & Van Lankveld, 2005) prior to ness and conformability in talking about sexual- identifying issues with treatment seeking. ity and attending to culture variables. Therefore Additionally, cultural norms may create barri- an important dimension to attend to is how the ers in treatment-seeking behaviors for deficits client(s) view their issue as well as their culture in sexual desire (Wincze & Weisberg, 2015). of origin’s conceptualization of their problem(s). This is in part due to men commonly being ste- Additionally, the use of self-report measures, reotypes as constantly eager for sex in many such as the FSFI (Rosen et al., 2000) or the Brief cultures (Wincze & Weisberg, 2015). Sexual Function Inventory-M (O’Leary et al., 1995), can serve as useful screening assessments Many clinical trials for MHSDD have sur- for those who are embarrassed or hesitant to ver- rounded hormonal therapies based on hypogo- bally address their sexual concerns. nadal treatments (Brotto et al., 2015). However, 352 R. T. Newlands et al. due to the high association between mood and is likely influenced by differences in the opera- MHSDD, research has oriented toward mental tionalizing of ED in different cultures (Rosen health and pharmacological treatments et al., 2004). Another difference in the reporting (Meuleman & Van Lankveld, 2005). There are of ED, which may influence treatment-seeking few controlled studies pertaining to efficacious behavior, is the differences in health issues in dif- psychosocial treatments of MHSDD (Beck, ferent countries (Rosen et al., 2004). For exam- 1995; O’Donohue et al., 1999; Simon, 2009), and ple, there are different prevalence rates of no studies exist to our knowledge examining comorbid and/or precipitating illnesses such as cross-cultural differences in treatment comple- diabetes, hypertension, depression, and anxiety tion and/or outcome for the disorder. Most stud- in other countries. Other countries also have vari- ies evaluating psychological treatment (either able levels of healthcare quality, which may alter alone or with pharmacological aspects) pertain to access to treatments for sexual dysfunction. established sex therapy, which utilizes Masters and Johnson (1970) model. The Masters and In psychogenic ED [ED resulting from cogni- Johnsons (1970) model entails “sex education, tive or interpersonal dysfunction (Melnik & nongenital and genital pleasuring, communica- Abdo, 2005)], variable results are often reported; tion training, and a variety of interventions however, psychosexual therapy is regularly used designed to reduce performance anxiety” (Beck, to treat ED that results from or is related to psy- 1995, p. 923). Although more research is needed, chopathology (Hatzimouratidis et al., 2010). cognitive behavioral therapy (CBT) has proven Other treatments for ED include surgical inter- efficacious in the treatment of MHSDD (Simon, ventions, intracavernous injections, vacuum con- 2009). The goals of CBT for MHSDD primarily striction devices, and hormonal and focus on altering the negative behaviors, atti- pharmacotherapies. Drugs like Viagra (silde- tudes, and thoughts in clients (Simon, 2009). nafil), Cialis (tadalafil), and Levitra (vardenafil) have proven effective in improving erections in Erectile Disorder/Dysfunction (ED) Erectile difficult to treat groups (Hatzimouratidis et al., dysfunction affects around 5–20% of adult men 2010). Though pharmacotherapy has proven to (Hatzimouratidis et al., 2010). Despite readily be an effective intervention for ED, there is the available and highly publicized treatments for potential for mild adverse side effects ED, treatment seeking remains low due to men (Hatzimouratidis et al., 2010), and rates of dis- being secretive about deficits in sexual function- continuation are high (Meuleman, 2002). ing (Meuleman, 2002). Differences in incidence Treatment attrition could be due to clinicians rates of ED are likely due to methodological vari- overlooking of life circumstances. When psycho- ability, varying age ranges, and socioeconomic genic factors in sexual dysfunction are ignored status of various samples collected in prior and are etiologically implicated, maintenance of research (Hatzimouratidis et al., 2010). Though erectile dysfunction can occur despite drug inter- age seems to account for some differences in ventions (Melnik & Abdo, 2005). The two main treatment-seeking behavior, there is evidence that psychological treatments used to treat psycho- culture plays an equally influential role. For genic ED include systematic desensitization and example, in a study completed by Tan et al. nonspecific sex therapy (Heiman, 2002). (2007), only 50% of Asian men who presented Additionally, psychotherapy for ED is effective with ED sought treatment, and treatment-seeking at ameliorating performance anxiety associated behavior was highly associated with spousal with sex, exploring sexual contexts, and altering influence. In European countries a common issue sexual scripts through psychoeducation (Althof associated with treatment-seeking behavior was & Wieder, 2004). However, it is imperative clini- that men did not want to take drugs to remedy cians remain mindful of cultural factors. For their sexual dysfunction (Shabsigh, Perelman, instance, in a study completed by Melnik and Laumann, & Lockhart, 2004). Treatment seeking Abdo (2005), clients that underwent psychother- 25 Cultural Considerations in the Treatment of Sexual Dysfunction 353 apy showed remission in erectile dysfunction Treatment for PE is dependent on the distress (ED). This decrease in dysfunction is attributable it causes the individual. Generally, PE treatment to the therapist’s cultural sensitivity where they is oriented toward psychosexual counseling, so considered barriers such as masculinity, taboos, long as there are not any comorbid genitourinary expectations of partners, and fear, especially of conditions (Hatzimouradtidis et al., 2010). failure (Melnik & Abdo, 2005). Though there are Psychological treatments for PE include the many pharmacological interventions to treat “stop-start program” (Semans, 1956), the physiological issues regarding ED, psychosocial “squeeze technique” (Masters & Johnson, 1970), disturbances can diminish treatment gains if and masturbation before sexual intercourse ignored (Althof & Wieder, 2004). (Hatzimouradtidis et al., 2010; Serefoglu & Saitz, 2012; Symonds et al., 2003). These techniques Premature Ejaculation (PE) Premature ejacu- have shown 50–60% effectiveness in short-term lation prevalence rate is around 20–30% use (Hatzimouradtidis et al., 2010). However, (Hatzimouratidis et al., 2010; Rowland, 2011). relapse is very common using these techniques Rates of PE remain fairly consistent across all alone and requires partner cooperation (Symonds demographics (Althof et al., 2010; Porst et al., et al., 2003). 2007) yet relatively little is known about the etiology of PE, which makes this form of sexual Delayed Ejaculation (DE) Of all male sexual dysfunction difficult to treat (Porst et al.,2007 ). dysfunction, DE is the least commonly reported Treatment-seeking rates for PE are also low. In a and as a result the least understood due to lack of large study by Porst et al. (2007), only 9% of research (McMahon et al., 2013; Rowland et al., their sample consulted a physician, and only 2010). The prevalence rate of DE is approxi- 4.2% visited a psychological specialist. Based mately 3–8% (Rosen, 2000), and it is often asso- on the findings by Symonds, Roblin, Hart, and ciated with other medical conditions or Althof (2003), it is clear that shame relates to interventions, such as surgical procedures related treatment avoidance, which is most likely cultur- to prostate issues, pharmacological side effect ally linked since shame is an emotion based in (primarily SSRIs), nerve/spinal issues/injury, and stereotypes and attitudes that are culturally multiple sclerosis (Rosen, 2000). Ejaculatory dif- determined (Gott & Hinchliff, 2003). ficulty is also associated with psychological and Interestingly around 75% of men with PE who interpersonal problems such as performance anx- sought treatment did so to increase the sexual iety and fear, specifically, fear of impregnation satisfaction of their partner, and 60% of men (Rosen, 2000). Like PE, prevalence rates are with PE stated they would seek treatment if their unclear due to failure to operationalize a concise partner recommended it (Porst et al., 2007), indi- definition that would lead to effective evaluation cating that treatment-seeking behavior may be criteria (DeRogatis & Burnett, 2008; McMahon contingent on effective communication between et al., 2013). Treatment-seeking behavior is often sexual partners. Cultural practices such as cir- related to issues in reproductive attempts cumcision, religion, and perceptions of sexuality (Rowland et al., 2010). may be responsible for any differences in treatment seeking (Montorsi, 2005). Treatment- Delayed ejaculation occurs at higher rates seeking behavior has not been established in among homosexual males, with prevalence sexual minority groups (e.g., men who have sex rates between 10% and 15% (Rosen, 2000; with men [MSM]) because most research has Simons & Carey, 2001). As previously focused on PE in relation to vaginal penetration expressed by Rowland et al. (2010), treatment- (Serefoglu & Saitx, 2012). Therefore future seeking behavior for DE is often associated efforts should be geared toward understanding with reproductive difficulties; however, this prevalence and treatment-seeking rates in sexual may not be an issue in homosexual men, which minorities. may lead to lower rates of treatment seeking. 354 R. T. Newlands et al.

Inhibited ejaculation in general is related with consider multiple treatment modalities when cultural or religious beliefs (McMahon et al., treating sexual dysfunction with multiple causes. 2004). Additionally, there are higher rates of inhibited ejaculatory response in orthodox reli- Currently, the most successful treatment gious communities (Perelman, McMahon, & employed is cognitive behavioral therapy (CBT), Barada, 2004), as sex may be viewed as sinful which focuses on altering negative attitudes (Jannini, Simonelli, & Lenzi, 2002; Masters & toward female sexuality and promoting comfort Johnson, 1970) or those cultures that have with one’s own body and sexuality (Kingsberg & taboos surrounding semen loss (Rowland et al., Althof, 2009; Meston, 2006). Other treatment 2010). All medical or psychological interven- aspects, such as sexual education, interpersonal tions should be tailored to target different eti- communication skills, and vaginal exercises, are ologies of DE (Rowland et al., 2010). treatment adjuncts that can be incorporated into Psychotherapy has been minimally investigated empirically supported CBT for FOD (Meston in treating DE. Current recommendations for et al., 2004). This treatment has been shown to treatment include client education about factors be effective at reducing anxiety surrounding sex- related to their ejaculatory dysfunction ual contexts that previously have been distress- (Waldinger & Schweitzer, 2005). According to ing (Kingsberg & Althof, 2009). One of the most Masters and Johnson (1970), treatment combi- important aspects of therapeutic intervention for nations pertaining to attention to sensate, nonsexual dysfunction is creating an environment vaginal penile stimulation and sexual technique conducive for discussing sexual problems modifications were 82.4% effective in treating (Kingsberg & Althof, 2009). Primary FOD treat- DE (Hendry et al., 2000). Treatments should ment success outcomes are around 90%, but sec- focus on relaxation and desensitization to ondary/acquired FOD treatment outcomes are reduce anxiety (Rowland et al., 2010) and less promising due to associations with other include the non-dysfunction party since the psychological disorders (Rosen & Leiblum, partner/spouse of a male with DE may feel 1995). In addition to CBT for FOD, it’s impor- inadequate or unattractive, resulting in marital tant to recognize the importance of communica- distress (Jannini et al., 2002). The most suc- tion between sexual partners. Poor cessful therapeutic intervention available for communication skills are impacted in FOD, and DE utilizes this model by combining general communication skills have been shown to be therapy interventions and self-pleasuring exer- effective in reducing FOD occurrences (Kelly, cises (Waldinger & Schweitzer, 2005). Strassberg, & Turner, 2006).

Female Orgasmic Disorder (FOD) Prevalence Female Sexual Interest/Arousal Disorder rates of FOD have ranged from as low as 3.5% to (FSIAD) Issues with desire and arousal are the as high as 34% (Líndal & Stefánsson, 1993; most commonly encountered sexual difficulties Lindau et al., 2007). However, due to the flawed for women of all ages (Kingsberg & Woodard, measures and difficulties operationalizing2015 ; Shifren et al., 2009; Simons & Carey, female sexual dysfunctions, current prevalence 2001). An estimated 10–38.7% of Western rates are unreliable (Latif & Diamond, 2013; women experience problems with sexual desire Meston, Hull, Levin, & Sipski, 2004), which and/or arousal (Shifren, Monz, Russo, Segreti, & obfuscates estimates about treatment seeking for Johannes, 2008; Simons & Carey, 2001), FOD. Treatment seeking may be influenced by although these prevalence rates vary with age. cultural factors, particularly in male-centered Given the recency of the new classification of the cultures (Graham, 2010). Female sexual dys- disorder, global prevalence rates and treatment- function is rooted in various etiologies such as seeking rates of FSIAD are unknown. Currently biological, emotional, and interpersonal (Latif & no empirically supported treatment for FSIAD Diamond, 2013), which is why it’s important to exists, likely due to the complexity of FSIAD as 25 Cultural Considerations in the Treatment of Sexual Dysfunction 355 well as the possible interaction of etiological Even when medical conditions are implicated, factors, which can make treatment challenging appraising psychosocial factors is crucial, as (Balzer, 2012). However, several different treat- these facets offer vital information regarding ments have garnered empirical support, includ- treatment options. Medical treatment may not be ing bibliotherapy (Balzer, 2012) and an option, and psychological treatments may mindfulness-based group psychoeducation inter- offer the most relief as they can assist clients and vention (Brotto, Basson, & Luria, 2008). their partner in coping with the pain (Wincze & Common elements of these treatments include Weisberg, 2015). All clients with sexual pain the integration of psychoeducation, CBT tech- should be assessed for thoughts and behaviors niques, mindfulness, sex therapy, and couples around their pain (specifically catastrophizing therapy, while also attending to body dissatisfac- and avoidance), psychological functioning, and tion, depression, beliefs regarding sexuality, and relationship and sexual difficulties (Boyer, relationship discord. While these treatments are Goldfinger, Thibault-Gagnon, & Pukall, 2011). promising, given the low attrition rate and posi- Given the high prevalence of physical and sexual tive outcomes, replications with non-western abuse in this population, clinicians should also populations are needed. assess for trauma (Harlow & Stewart, 2005). Finding the right treatment can be challenging, Genito-pelvic Pain/Penetration Disorder The given that sexual pain in women involves a com- prevalence of genito-pelvic pain/penetration plex interaction between physical, psychological, disorder is unknown, in part due to the recency and social factors (Boyer et al., 2011). Research of the term; however, roughly 15% of North shows that both chronic pain patients and indi- American women experience recurrent pain viduals with sexual pain demonstrate catastroph- during sexual intercourse. In previous iterations izing pain, fear of pain, pain-related anxiety, and of the DSM, genito-pelvic pain/penetration dis- avoidance of pain-inducing activities (Crombez, order was conceptualized as two distinct disor- Vlaeyen, Heuts, & Lysens, 1999; Payne, Binik, ders: dyspareunia and vaginismus. Rates of Amsel, & Khalifé, 2005; Vlaeyen & Linton, dyspareunia have been reported to range from 3 2000). For clients suffering from sexual pain to 43% (Van Lankveld et al., 2010; Wincze & without other co-occurring sexual dysfunctions, Weisberg, 2015), and rates of vaginismus have a history of sexual trauma, and distorted/mal- been estimated to range from 1% to 6% (Van adaptive attitudes about sex and whose pain is not Lankveld et al., 2010). The prevalence of vagi- specific to intercourse or a certain sexual activity, nismus is highest among highly patriarchal cul- treatment utilizing chronic-pain protocols may tures and among cultures in which arranged or offer promise (Payne et al., 2005). For clients forced marriages are practiced (Amidu et al., endorsing one or more psychosocial factors, 2010; Yasan & Gürgen, 2008). Only 60% of CBT-based treatments incorporating psychoedu- those experiencing sexual pain seek treatment, cation, cognitive restructuring, and self-coping and, of those, fewer still (60%) received a diag- statements in combination with pain-management nosis (Harlow, Wise, & Stewart, 2001). Little is strategies have demonstrated positive outcomes known regarding how culture moderates treat- (Bergeron, Rosen, & Pukall, 2014). ment seeking and/or completion. The varied etiological factors that may lead to genito-pelvic Incorporating Traditional Treatments pain/penetration disorder contribute to the lack Traditional medicine, or knowledge and prac- of an empirically supported treatment protocol. tices rooted in holistic views and cultural beliefs Additionally, untangling the physical and psy- sounding health and treatment of illness, are chological nature of the disorder is paramount commonly practiced in many cultures (WHO, in creating a treatment plan (Newlands & 2002) and have shown clinical utility in the O’Donohue, 2018). treatment of sexual dysfunction. Ayurveda tradi- 356 R. T. Newlands et al. tions recognized male sexual dysfunction and 2. Stimulus control stage: the therapist needs to created a specialty subfield devoted to sexual recognize and address the limited private health, vaajeekarana (Malviya, Malviya, Jain, space many Chinese couples are often faced & Vyas, 2016). This thousand-year-old tradition with. Additionally, they recommend a discus- recognizes the multifaceted nature of (male) sion of gender roles and the division of labor. sexual health and advocates lifestyle and dietary 3. Cognitive restructuring stage: Chinese clients practice as well as plant-based medicine for the are most likely to view cognitive restructuring amelioration of male sexual dysfunction as beneficial when the therapist is directive (Mishra, 2004). Indeed, many plant-based med- (Waxer, 1989); thus So and Cheung (2005) icine demonstrate clinical utility in the treat- recommend the therapist being directive and ment of male sexual dysfunction. See Malviya implementing behavioral assignments. et al. (2016) review for more information on the 4. Sensate focus stage: the therapist must strike a use of plant-based medicine for the treatment of delicate balance between instructing the indi- male sexual dysfunction. Demonstrating knowl- vidual in sensate focus (i.e., focus on sensa- edge of such medicinal approaches and/or tion and mutual pleasuring) and traditional incorporating traditional medicine into treat- Chinese beliefs that sex is reserved for procre- ment may increase client buy-in and result in ation and that women should be passive. decreased treatment dropout and ultimately cul- 5. Communication training stage: This stage can minate in higher treatment success. For instance, present difficulties, as open sexual communi- Cui et al. (2017) found that implementing tradi- cation is atypical and forging to many Chinese tional Chinese medicine was safe and effective couples (Xu, 1997). Li and Yan (1990) dealt for the treatment of PE, and when used in com- with this issue by having couples read sex bination with PE desensitization therapy, it was education literature aloud to one another with found to be more effective than PE desensitiza- the therapist and to read erotica and discuss tion therapy on its own. sex before going to bed. 6. Expanding sexual expression repertoires: Cultural Modifications Tailoring treatments to Generational differences may contribute to increase cultural acceptability has demonstrated some couples being more open to expanding success (D’Ardenne, 1986; Li & Yan, 1990; So their displays of affection (with younger gen- & Cheung, 2005). So and Cheung (2005) modi- erations being more accepting to overt affec- fied “western” sex therapy (consisting of education in China). However, Chinese couples tion, stimulus control, cognitive restructuring, have been found to hold a narrower range of sensate focus, communication training, and affectionate expression (Renaud & Byers, expanding sexual expression repertoires) for 1997). Additionally, Chinese couples (particu- Chinese couples and provided the following larly women) may hold taboos about novel recommendations: affectionate/sexual behaviors; thus therapists are advised to be aware of these qualms and to 1. Education stage: clinicians should advocate take a gradual approach. the importance of recognizing that talking about sex can be embarrassing or even taboo So and Cheung (2005) modification to sex among the Chinese, addressing somatic com- therapy for Chinese couples likely holds plaints recontextualizes the presenting prob- treatment utility with other east Asian cultures lem as a medical one, the use of traditional as well as cultures who advocate female passiv- medicine should not be discouraged, and more ity sexual encounters. However, replications in education may be necessary around the sexual other cultures are needed. Cultural modifica- response cycle and foreplay. 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Julia E. Maietta, Nina B. Paul, and Daniel N. Allen

Introduction cians and researchers with an accessible resource that will inform their practice and research. Schizophrenia spectrum and other psychotic dis- In this chapter, we begin with a review of the orders in the DSM-5 are disorders that are char- most up-to-date prevalence information, taking acterized by one or more psychotic symptoms in into consideration differences in geographic loca- five different symptom domains (hallucinations, tion, age, gender, and ethnic or racial background, delusions, disorganized thought, disorganized in order to help providers draw conclusions about behavior, and negative symptoms). Of these dis- their local base rates considering various cultural orders, schizophrenia, is diagnosed when symp- factors. We then provide an overview of psychotic toms are present in two or more of these five symptoms organized according to reality distor- domains. Schizophrenia is generally considered tion symptoms, disorganization symptoms, and the most severe psychotic disorder and is ranked negative symptoms, with a special emphasis on as one of the leading causes of disability in the identifying cultural influences on the expression USA which speaks to the psychological, medical, of these symptoms. We conclude with a discus- and financial burden it places on those it affects. sion of the DSM-5 Schizophrenia Spectrum and Over the past two decades, consideration of cul- Other Psychotic Disorder diagnostic criteria. tural factors has gained increasing importance in Because schizophrenia is considered the most research, assessment, and treatment of schizo- severe of these disorders and individuals with phrenia. Cultural factors include age, gender, schizophrenia can experience any of the psychotic sexual orientation, socioeconomic status, and symptoms listed in the DSM-5 criteria sets, our ethnic or racial background, among others. Much discussion primarily focuses on schizophrenia, new knowledge about the importance of these with the recognition that much of what is included and other factors has emerged over this time also applies to the other psychotic disorders. period, but there is an unmet need to review this research for behavioral healthcare providers. Such a review will fill this gap and provide clini- Prevalence of Schizophrenia Spectrum Disorders

J. E. Maietta · N. B. Paul · D. N. Allen (*) US Prevalence of Schizophrenia Department of Psychology, University of Nevada, Las Vegas, NV, USA The prevalence rate of schizophrenia is estimated e-mail: [email protected]; pauln1@unlv. nevada.edu; [email protected] to be between 0.3% and 0.7% with a lifetime risk

© Springer Nature Switzerland AG 2020 363 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_26 364 J. E. Maietta et al. of 1.0% (American Psychiatric Association selection of developed countries revealed that the (APA), 2013). Because a schizophrenia diagnosis impact of schizophrenia typically utilizes requires marked impairment in functioning, it is between 1.5% and 3% of the healthcare costs for common for long-term disability to occur and a nation (Knapp, Mangalore, & Simon, 2004). require lifelong treatment and continuing support This highlights the high level of burden that the from the individual’s social network. High levels functional impact of schizophrenia can have on of comorbid substance use and other psychiatric national healthcare expenditures. disorders contribute to a 20% shorter life expectancy for individuals with schizophrenia compared to the general population (Brown, Inskip, Gender and Age Differences & Barraclough, 2000). Despite having a relatively low prevalence rate, schizophrenia is the There is conflicting evidence in the literature 12th most disabling disorder out of 310 diseases regarding gender differences in prevalence and injuries that cause disability (Charlson et al., rates. Some authors report no significant gender 2018). This may be due to the need for lifetime differences in prevalence of schizophrenia support and treatment that results in substantial (Charlson et al., 2018), while others note a direct and indirect medical costs coupled with slightly higher prevalence rate of schizophrenia high unemployment rates (with estimates ranging in males (McGrath et al., 2004). It is apparent, between 61% and 88% unemployment). In 2013, however, that regardless of the conflicting evi- these costs were estimated to be $155 billion in dence for prevalence rate differences, there are the USA, which is approximately $44,773 per gender differences in symptom presentations/ patient annually (Cloutier et al., 2016). clusters (APA, 2013). Overall, it appears that men experience more negative symptoms (e.g., disorganization, catatonia, etc.) as well as more Global Prevalence Rates frequent comorbid substance use disorders, while women experience more positive (audi- Prevalence rates of schizophrenia are generally tory and visual hallucinations and delusions) stable across most of the globe (MacDonald, and affective symptoms (APA, 2013). Regarding 2015). A recent systematic review identified that treatment, women typically exhibit more posi- the global prevalence rate of schizophrenia is tive treatment response than men, and some 0.28%, with international rates varying between researchers have suggested that treatment for 0.33% and 0.75% (Charlson et al., 2018; Moreno- women should focus on reducing affective Küstner, Martín, & Pastor, 2018). Although rates symptoms, whereas treatment for men should are generally stable, some regions and countries focus on reducing comorbid substance use and do have differences. Notably, China demon- negative symptoms (Rena, Ma, Wang, Yang, & strated significantly higher rates of schizophrenia Wang, 2016). Additionally, age of onset of psy- relative to the rest of the world, the Netherlands chotic symptoms appears to be up to 3–5 years had higher rates relative to other European coun- earlier in men than in women who develop tries’ rates, and the lowest rates were reported for schizophrenia (APA, 2013). In general, men sub-Saharan Africa and North African/Middle tend to experience peak onset of diagnosis Eastern regions (Charlson et al., 2018). There has between 21 and 25 years old, and women expe- been research that indicates a geographic differ- rience peak onset between 25 and 30 years old ence in rates of schizophrenia, with those indi- and after 45 years old (Rena et al., 2016). viduals who are born closer to the equator Generally, however, prevalence rates show a demonstrating almost ten times lower prevalence peak prevalence at age 40, with a decline in rates than those born closer to the north and south prevalence noted in older age groups (Charlson poles (Kinney et al., 2009). A review of direct et al., 2018). This may be due to the high mor- and indirect healthcare expenditures across a tality and comorbid physical illness rates that 26 Cultural Considerations and Schizophrenia 365 are common in those with schizophrenia discussed in the research literature include the (Laursen, Nordentoft, & Mortensen, 2014; following: (a) African Americans may be more Saha, Chant, & McGrath, 2005). likely to utilize emergency or urgent care-type systems of healthcare when symptoms are most extreme, (b) miscommunication between African Ethnic Differences in Prevalence American patients and non-African American Rates providers, and (c) misinterpretation of cultural differences as symptomatic (Eack, Bahorik, Although prevalence rates of schizophrenia Newhill, Neighbors, & Davis, 2012). It may also appear to be relatively similar across the globe, be possible that higher rates of schizophrenia are there is evidence to suggest that the risk of devel- found in African American individuals; however, oping schizophrenia may vary based on immigra- given the research into possible diagnostic differ- tion and ethnic minority status (McGrath et al., ences based on the potential of clinical bias, it is 2004; Tortelli et al., 2015). For example, rates of currently unknown whether the rate of schizo- schizophrenia in Caribbean immigrant popula- phrenia is truly higher in African American indi- tions may be up to 2–4.5 times that of Caucasian viduals (DeCoux Hampton, 2007). Research has comparison groups (Bourque, van der Ven, & suggested that societal factors, such as social Malla, 2011). Some researchers have suggested density, socioeconomic status, and social disad- that the higher incidence rate of schizophrenia in vantage, may play a role in the higher rates of minority populations may be due to methodolog- schizophrenia in African Americans, with risk for ical issues in the published research in the area; diagnosis with a psychotic disorder being associ- however, it is apparent that there are environmen- ated with level of acculturation, minority status in tal factors that affect these differences, such as one’s community (e.g., less than 25% of the com- socioeconomic and cultural dissimilarity between munity being one’s race), and lower socioeco- the individual’s native and host country (Tortelli nomic status (particularly during childhood; et al., 2015). Even after accounting for method- Strauss & Culbreth, 2015). These sociocultural ological issues in past research in the area of eth- factors are posited to be influential in later receiv- nic differences in schizophrenia prevalence rates, ing a diagnosis of schizophrenia in individuals there still appears to be a higher rate of schizo- who may already be at a higher genetic risk phrenia in Caribbean immigrant populations as (Strauss & Culbreth, 2015). well as black ethnic minorities (Qassem et al., Regarding other non-African American indi- 2015; Tortelli et al., 2015). Research has individuals, there is currently no clear evidence indicated that prevalence rates of schizophrenia in cating similar patterns of misdiagnosis and/or migrant populations are lower when countries are ethnic prevalence differences for Hispanic, Asian, more similar (Western and Western), than when or American-Indian individuals; however, some countries are culturally dissimilar (Western ver- research has demonstrated a possible increased sus Eastern) indicating that social factors such as rate of schizophrenia diagnosis in Hispanic language and other relevant cultural factors may Americans compared to Caucasians (Blow et al., be more important for these higher incidence 2004; Chien & Bell, 2008). Regardless of the rates than immigration status alone (Schwartz & current status of the literature on prevalence rates Blankenship, 2014). of schizophrenia by race/ethnic minority status, Migration status aside, there appears to also misdiagnosis of schizophrenia in individuals who be a significant rate of overdiagnosis of schizo- do not truly have the disorder can lead to incor- phrenia in African American individuals, with rect and even harmful pharmacological therapies African Americans diagnosed with schizophrenia as well as negative outcomes due to stigma as much as four times the rate of Caucasian indi- (Cook, Reevves, Teufel, & Postolache, 2015). It viduals (Barnes, 2013; Chien & Bell, 2008). is therefore vitally important that clinicians are Potential reasons for this disparity that have been trained to recognize cultural differences across 366 J. E. Maietta et al. ethnic groups that may impact diagnosis of toms within each domain and unique terminol- schizophrenia. ogy used in their descriptions. To the extent that the symptom constructs are not transcultural or the definitions differ from one culture to the next, Symptoms of Schizophrenia variability in diagnoses are anticipated with an Spectrum and Other Psychotic associated decrease in reliability and criterion- Disorders related validity of the diagnosis. Thus, from a cross-cultural perspective, it is important that Schizophrenia spectrum disorders are character- psychotic symptoms are clearly defined so that ized by the presence of psychotic symptoms, they may be accurately identified in clinical and although such symptoms can be present in other research settings. To accomplish this, the next medical and psychiatric conditions (Fujii & sections contain detailed descriptions of the most Ahmed, 2007). The term psychotic disorders, common symptoms in the five DSM-5 domains however, often refers to the Diagnostic and for a diagnosis of schizophrenia. Structured and Statistical Manual of Mental Disorders, Fifth- semi-structured interviews to determine the pres- Edition (DSM-5) section on Schizophrenia ence and severity of psychotic symptoms have Spectrum and Other Psychotic Disorders (APA, done much to develop detailed descriptions and 2013). Schizophrenia spectrum disorders are examples of the core symptoms of schizophrenia, diagnosed based on the presence of symptoms in and the definitions provided in the following sec- one or more of five symptom domains that tions are derived from some of these symptom include reality distortion symptoms (delusions interviews (Andreasen, 1982, 1984, 1989; Kay, and hallucinations), disorganized symptoms (dis- Fiszbein, & Opler, 1987; Kirkpatrick et al., 2011) organized thinking and disorganized or abnormal as well as the DSM-5. The discussion is orga- motor behavior), and negative symptoms (blunted nized into three sections that include: (1) Reality affect, avolition, asociality, etc.). Distortion Symptoms, (2) Disorganization Symptoms in these five general domains can Symptoms, and (3) Negative Symptoms. be quite complex with multiple individual symp- Figure 26.1 provides a useful heuristic for orga-

RDI§§DIS NEG

HAL DELBTHO EH ANH† AVO† ASO† BLU‡ ALO‡

Fig. 26.1 Symptom dimensions in schizophrenia spec- DEL delusions, THO thought, BEH behavior, ANH anhe- trum and other psychotic disorders. RDI reality distortion donia, AVO avolition, ASO asociality, BLU blunted affect, symptoms, DIS disorganized symptoms, NEG negative ALO alogia, † motivation and pleasure (MAP) domain, ‡ symptoms, § positive symptoms, HAL hallucinations, diminished expressivity (EXP) domain 26 Cultural Considerations and Schizophrenia 367 nizing psychotic symptoms under these three conspired against, or will be harmed by another general domains. person or organization. For example, individuals might describe conspiratorial plots in which others are trying to poison them, foreign spy Reality Distortion Symptoms: agencies (e.g., FBI, CIA, etc.) are tapping their Hallucinations and Delusions phones, or all bus passengers on their route home are following them in order to hurt or kill Positive symptoms of psychosis refer to those them. symptoms that represent thoughts, feelings, and • Delusions of reference are present when the behaviors that are not typically present in healthy individual believes that an insignificant or people. Delusions and hallucinations have been impersonal remark, person, event, or object in referred to as positive symptoms because they the environment has special meaning or refers represent beliefs or perceptual experiences that directly to the individual. For example, feeling are outside normal human experiences. Factor that something on the radio or on TV was analysis studies of schizophrenia symptoms sug- meant especially for them or was meant to gest that hallucinations and delusions load on a give them a special message. single factor that is distinct from negative symp- • Grandiose delusions are present when the toms and disorganization symptoms, each of individual believes that he or she possesses which also loads on their own factors (e.g., extraordinary abilities, powers, knowledge, Bilder, Mukhergee, & Rieder, 1985). Because and resources or has a special mission or pur- disorganization symptoms (discussed later in the pose. For example, individuals might believe chapter) are also considered positive symptoms, that they are going to be an all-star in the NFL hallucinations and delusions have also been even though they have never played football. referred to as reality distortion symptoms to dis- • Religious delusions are false beliefs of a reli- tinguish them from disorganization symptoms. gious nature often involving historical religious figures, special religious missions or Delusions Delusions are false beliefs that devi- callings, or personalized new religious sys- ate substantially from what is considered normal tems. For example, individuals might describe and that cannot be attributed to cultural back- that they are the next Messiah sent on a special ground or normative religious beliefs. When mission to cleanse the world of sin. severe, delusions are firmly held and unques- • Erotomanic delusions are false beliefs that tioned by the individual who experiences them, someone is in love with or engaging in a even when presented with evidence to the con- romantic relationship with the affected trary, and these delusions have a substantial individual. impact on behavior. Delusions that are mild in • Somatic delusions are present when there is a severity may be periodically questioned and preoccupation with health accompanied by have little impact on behavior. Delusions should unfounded beliefs about medical illness or be distinguished from strong beliefs in that indi- unusual changes in bodily functions or appear- viduals with strongly held beliefs demonstrate ance. For example, individuals might be flexibility in evidence testing of that belief, for convinced that they have cancer despite evi- example, when they are presented evidence to dence from multiple diagnostic tests that they the contrary of their beliefs. Delusions have been do not. categorized according to a variety of themes and • Guilt or sin delusions are false beliefs of com- we present some of the more common themes mitting a grave unforgivable sin or inappropri- below. ate preoccupation and guilt over things done wrong. For example, individuals might believe • Persecutory or paranoid delusions are false that they were responsible for a major disaster beliefs that the individual is being persecuted, (e.g., hurricane, flood, etc.) that occurred 368 J. E. Maietta et al.

when there is no possibility that they were Because it is not possible to be an expert on truly responsible. every culture, when a clinician is uncertain, it is • Bizarre delusions refer to a type of delusion often useful to ask the individual if others in his for which there is no plausible explanation or her same culture or religion have similar and that cannot possibly be true. Examples beliefs. Take the example above. A clinician include delusions of thought withdrawal might say: “I am not as familiar with your reli- where the individual believes that thoughts are gion. Help me to understand better. Are other being taken out of their mind by someone or people in your religion also on this same mission, something outside of themselves; thought or is the mission special to you?” From the exam- insertion, where the individual believes that ple above, all other individuals in the woman’s someone else’s thoughts are being inserted religious circle might believe that each is a saint into their mind; or delusions of control, in who has a special mission from God and that which the individual believes that someone or there will be an Armageddon in the end of time. something else is controlling the individual’s However, they might very well view the woman’s actions or feelings. The belief that one’s brain beliefs as quite unusual because of the central has been removed and replaced with the brain role she believes she plays in the religion (histori- of another would also be an example of a cal figure, mission to save the world from destruc- bizarre delusion. tion, unique role in end time prophecies, etc.). Considering impact on behavior may also help Cultural Considerations for Diagnosing identify delusional beliefs. For example, an indi- Delusions From a cultural perspective, delu- vidual who is suspicious about the possibility of sions may be particularly difficult to diagnose being poisoned by airplane condensation trails given the sometimes dramatic differences in (contrails) but who does not alter his or her belief systems among individuals from various behavior in response to this idea would probably cultures and backgrounds. For example, an indi- not meet criteria for a paranoid/persecutory delu- vidual who reports being on a special assignment sion. However, if the same individual purchased from NASA to land a space rover on Jupiter may and wore a gas mask when leaving home, wrote at first appear to be experiencing a grandiose threatening letters to the airlines accusing them delusion. If this individual’s highest level of edu- of poisoning the world, and called local TV and cation is 2 years of college and they are not radio stations to raise alarm about the poisoning, employed by NASA, then their belief is more there is a much greater likelihood that the belief likely delusional, as compared to an aeronautical would meet the criteria for a delusion. engineer who lives in Houston and is gainfully employed by the space agency. Hallucinations Hallucinations are false perceptual experiences that occur in the absence of cor- Individuals may experience delusions that are responding external sensory stimuli. These may quite simple, often conforming to one of the delu- occur in any sensory modality (auditory, visual, sional types described above, but it is also quite tactile, olfactory, gustatory). Hallucinations common for there to be a combination of delu- should be distinguished from illusions, the latter sional themes. For example, a woman may believe of which represent a misperception or distorted that she is a historical religious figure (religious perception of an existing external stimulus (e.g., delusion) who is being persecuted (paranoid/per- seeing an actual shadow and perceiving that it is secutory delusion) because she is on a special a human figure when it is the shadow of a nonhu- mission to save the world (grandiose delusion) man object). They should also be distinguished from the Armageddon. This type of complex delu- from hypnogogic and hypnopompic phenomena, sion may become quite systematized so that all which are hallucinatory experiences that only events, perceptions, feelings, and actions become occur when one is falling asleep or waking up. aligned with the core delusional belief system. Illusory misperceptions and hynogogic/hyno- 26 Cultural Considerations and Schizophrenia 369 pompic phenomena do not meet criteria for a hal- during intoxication or withdrawal do not meet lucination in DSM-5 psychotic disorder criteria. criteria for visual hallucinations. Additionally, Likewise, substances or medical conditions may when visions of religious figures are present, cause hallucinations, but these should also not be the normative religious culture should be con- considered as meeting criteria for a schizophre- sidered (e.g., “[God, Jesus, etc.] came to me nia spectrum disorder. In schizophrenia, the most and I felt/saw his/her presence…” may be nor- common hallucinations are auditory hallucina- mative in certain religions). tions (64–80%), visual hallucinations (23–31%), • Olfactory hallucinations involve the percep- and tactile hallucinations (9–19%) (McCarthy- tion of unusual odors that are typically Jones et al., 2017). Numerous neuroanatomical/ unpleasant in the absence of an external stim- neurophysiological differences have been docu- ulus that could account for the odor. Patients mented in individuals with schizophrenia. For may report smelling feces, blood, and burning example, the relatively higher prevalence of audi- or may believe that they themselves have an tory hallucinations is consistent with well- unpleasant odor. documented abnormalities in primary auditory • Tactile hallucinations involve experiencing cortex (Mørch-Johnsen et al., 2017; Ramage, unusual physical sensations such as numb- Weintraub, Allen, & Snyder, 2012). Regardless ness, tingling, burning, or the feeling of insects of sensory modality, hallucinations are most crawling on or under the skin (formication). often perceived as unpleasant, cause distress, Notably, these tactile hallucinations are in the influence behavior, and negatively impact func- absence of any medical cause (e.g., neuropa- tional outcomes. thy, delirium tremens). Individuals may also perceive that their body has changed in • Auditory hallucinations include hearing appearance or shape when it actually has not. voices, noises, or sounds (including music). • Gustatory hallucinations consist of unusual Typically, voices speak to or call out the indi- tastes that are typically unpleasant and may vidual’s name in the absence of corresponding correspond to those experienced in olfactory external auditory stimuli. In more rare hallucinations. It is often difficult to distin- instances, the hallucinatory voice may com- guish between olfactory and gustatory halluci- ment on the person’s behaviors (providing a nations, given the close links between the running narrative), or there may be two voices perception of taste and smell. Evidence for conversing with each other. Voices may be gustatory hallucinations may be most clearly perceived as cruel or critical and, in severe established in the absence of olfactory halluci- cases, may command individuals to carry out nations. For example, a gustatory hallucina- acts that may be harmful to themselves or oth- tion may be present when an individual ers (which are referred to as command perceives that their food tastes rancid, although hallucinations). others who taste the same food think it tastes • Visual hallucinations are the false perception as it should. of shapes, objects, colors, or most typically figures of people. Because visual hallucina- Cultural Considerations for Diagnosing tions often involve human figures, it is impor- Hallucinations Hallucination-like experiences tant to distinguish them from hypnogogic and may occur normatively in different cultures. For hypnopompic hallucinations which are com- example, in some cultural groups, it is not unusual mon and may involve, for example, a person to see or hear a loved one who has passed away as seeing a “figure” or “spirit” hovering over the a part of the grief process. This would not count bed as he or she is falling asleep. Similarly, as an auditory or visual hallucination. Likewise, medical conditions with associated visual per- some religious cultures have a close link to their ceptions (e.g., “aura’s” that precede migraine deity that includes perceptual experiences (e.g., headaches) and those induced by substances the deity might tell a person to make some deci- 370 J. E. Maietta et al. sion over another decision, etc.). This would not spontaneous speech shift from one thought to be a command hallucination, but rather a normal another that is indirectly related or even unre- part of the individual’s religious culture. Different lated. There may be only a vague connection perceptual experiences should always be dis- between ideas, but oftentimes there is a lack of cussed in depth with the individual and should meaningful relationships between ideas. As include a discussion of the individual’s cultural speech continues, the individual gets farther context in order to distinguish between normative and farther off track with little awareness that cultural experiences and nonnormative experi- this is occurring. Andreasen (1979) notes that ences that may be more likely to meet DSM-5 there is often a lack of cohesion between criteria for hallucinations. clauses and sentences as well as unclear pro- noun references. Andreasen (1979) provides an example of a patient response below: Disorganization Symptoms –– Interviewer: “Did you enjoy college?” –– Patient: “Um-hm. Oh hey well I, I oh I Disorganized symptoms are also defining fea- really enjoyed some communities I tried it, tures of DSM-5 psychotic disorders and can be and the, and the next day when I’d be going further broken down into disorganized thinking out, you know, um, I took control like uh, I and disorganized behaviors. put, um, bleach was on my hair in, in California. My roommate was from Disorganized Thinking Disorganized think- Chicago and she was going to the junior ing, also referred to as thought disorder or for- college.....” mal thought disorder, is evidenced by • Tangentiality is present when the individual’s disorganized speech. Speech abnormalities can response to a question is tangential or irrele- be quite severe, sharing common features of vant. While similar in some respects to derail- acquired language disturbances resulting from ment, some researchers suggest that damage to cortical and subcortical central lan- tangentiality is distinct in that it applies spe- guage centers in the brain (e.g., aphasias fol- cifically to situations where a question is being lowing stroke). Thought disorder in answered, rather than abnormal transitions schizophrenia is characterized by a breakdown that occur during the course of spontaneous in the normally logical structure of language, speech. Andreasen (1979) provides the fol- such that as the thought disorder worsens, lowing example: speech may become completely incomprehen- –– Interviewer: “What city are you from?” sible. In less severe cases, speech may be vague, –– Patient: “That is a hard question to answer with an overreliance on broad generalizations. because my parents … I was born in Iowa, Disorganized symptoms are less stable than but I know that I’m white instead of black positive or negative symptoms (Peralta & so apparently I came from the North some- Cuesta, 2001) and appear to fluctuate when where and I don’t know where, you know, I treatment is effective and there is remission of really don’t know whether I’m Irish or thought disorder. Researchers have attempted Scandinavian.....” to classify the degree and type of disorganized • Circumstantiality is characterized by speech thinking evidenced through pattern and content that is indirect in the process of answering a of speech. Some of the more common types of question or providing an explanation. thought-disordered speech are listed and Responses are characterized by inclusion of described below. many marginally related details that delay the individual in getting to the point. Answers are unusually long and drawn out, and the indi- • Derailment, also referred to as loose associa- vidual may even need to be interrupted in tions, is present when the ideas conveyed in order to reach the point. Circumstantiality dif- 26 Cultural Considerations and Schizophrenia 371

fers from derailment and tangentiality in that making sense (cents) anymore. I have to circumstantial responses eventually address make dollars” (Andreasen, 1979). the point of the question or explanation. Andreasen (1979) provides the following example: Cultural Considerations for Diagnosing –– Interviewer: “Tell me what you are like, Disorganized Speech From a cultural perspec- what kind of person you are.” tive, disorganized speech may be misdiagnosed if –– Patient: “Ah one hell of an odd thing to say the examiner does not recognize linguistic differ- perhaps under these particular circum- ences in narration (e.g., some cultures have a stances, I happen to be quite pleased with more longwinded narrative style than typically who I am or how I am and many of the Western cultures). Also, if the interview is con- problems that I have and have been work- ducted in a language which is not the client’s first ing on I have are difficult for me to handle language, lack of language proficiency may be or to work on because I am not aware of misinterpreted as symptoms of thought disorder. them as problems which upset me Similarly, linguistic colloquialisms of subcul- personally.” tures may be incorrectly seen as a derangement • Incoherence, also referred to as word salad or of speech if the examiner is not familiar with schizophasia, is a relatively rare disturbance them. that is characterized by speech that is incom- prehensible because of disorganization at the level of the sentence or clause (as opposed to Disorganized Behavior Disorganized or abnor- derailment where the abnormality is between mal motor behavior is also variable in presenta- the abnormal connections between sentences tion and can include things such as catatonia and or clauses). The abnormality is so severe that motoric mutism, childlike silliness, unpredict- it may closely resemble speech in fluent apha- able agitation, or problems in goal-directed sias that result from damage to Wernicke’s behavior (APA, 2013). Disorganization of behav- area. Andreasen (1979) provides the following ior can be identified by direct observation and example of incoherent speech: information from collateral sources or from the –– Interviewer: “Why do people comb their patient himself. This behavior is often unusual hair?” and bizarre, even within the individual’s cultural –– Patient: “Because it makes a twirl in life, context. In assessing for disorganized behavior, my box is broken help me blue elephant. one should keep in mind that behavior that is due Isn’t lettuce brave? I like electrons. Hello, to the direct effects of a substance (e.g., beautiful.” medication, alcohol, drugs) does not meet criteria • Clanging is a pattern of speech in which for this symptom presentation. Individuals may sounds rather than meaningful relationships present with different aspects of bizarre/disorga- appear to govern word choice, so that the nized behavior that can include odd or unusual intelligibility of the speech is impaired and appearance, inappropriate social or sexual behav- redundant words are introduced. In addition to ior, unusually aggressive or agitated behavior, rhyming relationships, this pattern of speech and repetitive or stereotyped behaviors as well as may also include punning associations, so that catatonia. Each of these aspects of disorganized a word similar in sound brings in a new behavior is described in more detail below. thought. For example: Examples are from real patients as described in –– Patient: “I’m not trying to make a noise. the Scale for the Assessment of Negative I’m trying to make sense. If you can make Symptoms (SANS; Andreasen, 1989) and the sense out of nonsense, well, have fun. I’m Scale for the Assessment of Positive Symptoms trying to make sense out of sense. I’m not (SAPS; Andreasen, 1984) manuals. 372 J. E. Maietta et al.

• Clothing and appearance may reflect disor- who shouts a vulgar sexual remark about a ganized behavior when they are significantly stranger on a subway train car. outside of the norm for the individual’s cul- • Aggressive and agitated behavior is often tural and socioeconomic situation. A person unpredictable and can occur in any context. may, for example, wear very heavy coats in For example, an individual may aggressively the hottest months of summer. Another indi- shout at a stranger on the street or write threat- vidual may wear no shoes, very torn jeans, ening letters to government officials or others. and a tarp fashioned into a tunic with letter- A person might also start arguments with ing saying that he is the “Facebook president friends, family members, or complete strang- of the world.” Clothing may be dirty and ers. These arguments are usually inappropri- appear disheveled. In making judgments ate and are typically not congruous with the about the appropriateness or bizarreness of a situation that triggered the anger. For exam- person’s appearance, care should be made to ple, someone might berate his little sister and determine if the person’s appearance is based call her vulgar names for making a comment on external factors, such as socioeconomic about not liking rain. Occasionally, this situation that may give a person little to no aggressive behavior may include acts of vio- choice over their clothing options, or other lence toward animals or other humans or situational factors that may be present (e.g., destruction of property. Violent acts toward bizarre dress or appearance that is intended other people may be triggered by a disagree- to attract attention in an individual who is not ment or perceived slight but are often out of psychotic). Additional care should be used proportion to the situation entirely. For exam- not to make assumptions about particular ple, a man might stab his wife for not putting aspects of appearance or dress that are cultur- enough paprika in his dinner. ally relevant. For example, a particular hair- • Repetitive or stereotyped behavior can include style or dress may be an external rituals that the individual feels he or she must representation of one’s faith and should not perform. Often these rituals have some sort of be characterized as unusual or bizarre specific symbolism or importance for influ- behavior. encing the person’s life. For example, an indi- • Social and sexual behavior that meets criteria vidual may eat foods in a particular order in an for disorganized behavior is typically grossly attempt to control the weather for the next day. inappropriate for the context. Regarding sex- In assessing this type of disorganized behav- ual behavior, for example, an individual may ior, it is important to rule out behavior that expose his or her genitals in public (however, occurs in the context of obsessive-compulsive this should be diagnostically differentiated disorder (OCD) as those with OCD often per- from exhibitionistic disorder). Individuals form rituals in an attempt to control certain may masturbate, urinate, or defecate in inap- aspects of their life (e.g., not stepping on propriate areas or receptacles. Social behavior cracks to ensure the safety of their mother or that is considered bizarre may include things themselves). Compulsions in the context of like muttering to oneself while walking down OCD do not meet criteria for disorganized the street or shouting abruptly in a crowd. behavior as they are primarily related to the Making inappropriate sexual remarks to obsessions that occur in OCD. Another con- strangers can also qualify as bizarre if it is sideration for this type of behavior is rituals grossly inappropriate to the situation. For that occur in religious or other cultural con- example, making a sexual remark to someone texts that would not meet criteria for this type that an individual has been in contact with and of disorganized behavior. is attracted to may not be in good social form, • Catatonia is characterized by a significant but would be less likely to meet criteria for decrease in interaction with one’s environ- bizarre behavior as compared to an individual ment. This may include rigid, often bizarre, 26 Cultural Considerations and Schizophrenia 373

postures accompanied by waxy and resistant influences and so are not core features (Carpenter flexibility when a limb is moved. Other mani- Jr., Heinrichs, & Wagman, 1988; Kelley et al., festations of catatonia can include mutism and 1999). Examples of secondary negative symp- stupor (lack of verbal and motor output), gri- toms that are not core features of psychotic disor- macing (unusual facial expressions that are ders but rather are caused by secondary influences not situational or transient in nature), or echo- include but are not limited to antipsychotic medi- ing of speech (echolalia). It is important to cation side effects causing affective flattening, note that catatonic features have historically depression causing anhedonia, or paranoia caus- been associated with schizophrenia, but the ing asociality (Kirkpatrick, Buchanan, DSM-5 now classifies catatonia as a specifier McKenney, Alphs, & Carpenter, 1989). as it can occur in other disorders or medical Functionally, primary negative symptoms are conditions (e.g., major depressive disorder more stable than positive or disorganized symp- with catatonia) in addition to occurring in toms because they are less responsive to antipsy- schizophrenia. chotic medications (Carpenter, Conley, Buchanan, Breier, & Tamminga, 1995) which Again, it is important for clinicians to famil- leads to high incidence of residual negative iarize themselves with the client’s culture to symptoms during or following treatment avoid misdiagnosing culturally normative appear- (Carpenter et al., 1988). Definitions of the five ance or behavior as symptoms of disorganization. negative symptoms are provided in the following For example, some cultures may dress in colors sections based on the Brief Negative Symptom or garments that the examiner is not familiar Scale manual (BNSS; Kirkpatrick et al., 2011), with, may express anger more openly, or may which is a second-generation negative symptom engage in ritualistic behaviors that are a normal rating scale that was developed based on the part of their spiritual or religious beliefs. NIMH negative symptoms consensus statement (Kirkpatrick, Fenton, Carpenter, & Marder, 2006). Negative Symptoms • Asociality is significantly reduced social activ- Negative symptoms are an absence or decrease in ity with a decreased interest in establishing behaviors and subjective experiences that are close relationships. Asociality must be distin- normally present in a person from the same cul- guished from social withdrawal based on par- ture and general age group. In the DSM-5, nega- anoid ideas or paranoid delusions (e.g., tive symptoms are described in relation to the two withdrawing from others because of a delu- overarching domains of motivation and pleasure sion about being persecuted by others would (MAP; anhedonia, avolition, asociality) and not count as asociality). Asociality involves diminished expressivity (EXP; blunted affect, significant apathy which is based on the alogia), although recent research suggests that degree to which the individual desires and val- negative symptoms are better conceptualized ues close relationships (internal experience) according to the five symptom dimensions that as well as the extent to which the individual compose the MAP and EXP domains: anhedonia, interacts with others (external behavior). avolition, asociality, blunted affect, and alogia External behavior and internal experience (Kelley, van Kammen, & Allen, 1999; Strauss may, however, be quite different as behavior et al., 2018). A distinction is made between pri- may not be congruent with internal experi- mary negative symptoms, which are stable core ence. For instance, an individual may be iso- features of the psychotic disorder, and secondary lated because of poor social skills or negative symptoms which result from secondary persecutory delusions—resulting in a high 374 J. E. Maietta et al.

impairment—but may feel very lonely, think waving), head (e.g., nodding), shoulders (e.g., about other people a great deal, and wish for shrugging), and trunk (e.g., leaning toward or companionship. This would not meet criteria away from someone). In vocal expressiveness, for asociality. blunted affect is often determined because • Anhedonia is a decreased expectation or actual there is no change in the normal variations in feeling of pleasure from engaging in pleasur- the speed, volume, and pitch of vocal output. able activities. This results in significantly • Alogia refers to impoverished thinking and decreased intensity and frequency of pleasur- cognition evidenced by a significant decrease able activities that one previously enjoyed. in the quantity of spoken words. Little to no Anhedonia often encompasses all potential verbal responses are often seen when individ- sources of pleasure during an activity as well uals are asked questions or when attempting to as expected or anticipated pleasure from a engage in conversation with an individual future activity and can include things such as exhibiting alogia. Sometimes individuals will social activities, physical sensations, recre- respond to a direct question but will not pro- ational activities, and work/school. vide any information beyond what is strictly • Avolition is a reduced desire, initiation, and necessary in order to answer the question that persistence in an activity resulting in an was asked. inability to mobilize to initiate or persist in many different kinds of tasks. It is important Cultural Considerations for Diagnosing Negative to consider both anhedonia (the pleasure Symptoms Factor analytic studies demonstrate associated with the task) and avolition (the that the structure of negative symptoms appears initiation and persistence on a task) sepa- stable across cultures (Ahmed et al., 2019), but rately. Like asociality, an individual would there is little empirical information that addresses not meet criteria for avolition if he or she still differences in severity of these symptoms as they has a desire to engage in such behavior. For relate to culture. Even in the absence of such example, individuals who are depressed information, culture may influence perceived (rather than psychotic) may experience avoli- severity of negative symptoms. For example, cul- tion-like symptoms; however, they often have tural differences in emotional expression may accompanying guilt or shame about their lack influence perceived severity of blunted affect so of accomplishment, which would not meet that individuals from cultures that are more criteria for avolition under DSM-5 psychotic reserved in their expression of emotion may be symptoms. perceived as having higher levels of blunted • Blunted affect is a decrease in the outward affect. In some Asian cultures, for example, expression of emotion with impoverished expressing strong emotions is not considered expression, reactivity, and feeling. Blunted appropriate and could be confused with symp- affect can be determined based on a few types toms of blunted affect. Similarly, in some cultures of expressive behaviors including facial fea- the way one responds to questions may be brief tures, gestures, and vocal changes that express (e.g., individuals from some Latin cultures may emotional experiences. Changes in facial express respect for doctors by responding with expression can include facial movements in brief answers in order to not take up too much the eyes, mouth, and other parts of the face. In time, which may be misinterpreted as alogia). In blunted affect, a person may not raise their general, clinicians can foster a culturally sensitive eyebrows, smile, or even wrinkle their nose assessment by increasing their awareness of com- when disgusted. Expressive gestures are seen mon differences in social expression across cul- in normal conversation and include move- tures particularly as they relate to behavior that ments made with the hands (e.g., pointing or may be confused with negative symptoms. 26 Cultural Considerations and Schizophrenia 375

Diagnosis of Schizophrenia identified, it is initially important to determine Spectrum and Other Psychotic whether they are consistent with the diagnosis of Disorders a primary psychotic disorder or are related to a secondary source. Psychotic symptoms that only DSM-5 Diagnoses occur during symptom exacerbation of another mental disorder (e.g., major depressive disorder, Disorders included in the Schizophrenia bipolar disorder) are unlikely to be diagnosed as Spectrum and Other Psychotic Disorders section a primary schizophrenia spectrum disorder. of the DSM-5 may be divided into two general Similarly, psychotic symptoms that only occur categories; primary psychotic disorders are con- during the presence of substance intoxication or sidered part of the schizophrenia spectrum, and withdrawal or begin after the onset of a medical secondary psychotic disorders that are caused by condition that is known to cause psychotic symp- a condition other than a psychotic disorder (e.g., toms are also unlikely to meet diagnostic criteria medical condition, substance induced). Primary for a primary schizophrenia spectrum disorder. In disorders include delusional disorder, brief psy- instances where psychotic symptoms are deemed chotic disorder, schizophreniform disorder, to be secondary, the clinician may assign a diag- schizophrenia, and schizoaffective disorder. nosis of substance-/medication-induced psy- Schizotypal personality disorder is also included chotic disorder, psychotic disorder due to another in this section as it is considered part of the medical condition, or another mental disorder schizophrenia spectrum. Secondary psychotic with a psychotic symptom specifier, such as disorders include substance-/medication-induced major depressive disorder, with psychotic fea- psychotic disorder and psychotic disorder Due to tures. These diagnoses can be difficult to estab- another medical condition, where the cause of the lish, but in order for them to be made, there must psychotic symptoms is related to the effects of a be clear evidence that the psychotic symptoms substance or another medical condition. New to are temporally linked to the medical condition or the DSM-5 is the criteria set for diagnosis of substance and that the medical condition or sub- catatonia, which is not considered a separate dis- stance can cause the symptoms. Regarding the order but is conceptualized as a specifier that can former, psychotic symptoms that begin before the (1) co-occur with another mental disorder, onset of a medical condition or occur outside including a schizophrenia spectrum disorder, (2) periods of substance intoxication or withdrawal co-occur with a medical disorder, or (3) be caused are unlikely to meet diagnostic criteria. Regarding by an unknown medical or mental condition. This the latter, the DSM-5 provides helpful guidance latter category may also be used to indicate diag- by presenting psychotic symptoms that arise nostic uncertainty when there is not enough from common medical conditions and sub- information to make a diagnosis or in cases where stances. For example, the DSM-5 indicates that full criteria for the catatonia specifier are not met. cannabis can be associated with symptoms of a The two other diagnoses in this section are other psychotic disorder but not with symptoms of specified schizophrenia spectrum and other psy- bipolar or depressive disorders during chotic disorder and unspecified schizophrenia intoxication. Alcohol is associated with symp- spectrum and other psychotic disorder. Of the toms of a psychotic disorder during both intoxi- primary psychotic disorders, schizophrenia is cation and withdrawal. However, neither cannabis typically considered the most severe. nor alcohol is associated with symptoms of OCD, While one or more symptoms from the five and so a diagnosis of alcohol-related OCD would symptom domains often co-occur in patients with not be appropriate. Additionally, from a cultural these diagnoses, accurately characterizing the perspective, a diagnosis would not be made for presence and pattern of symptoms is imperative psychotic symptoms that arise from substances because it provides the basis for DSM-5 differen- used for religious purposes nor would culturally tial diagnosis. Once psychotic symptoms are sanctioned reactions to medical conditions. 376 J. E. Maietta et al.

For psychotic symptoms that are not second- mania and depression are present. Psychotic ary, the DSM-5 recommends that clinicians con- symptoms that result from substances or medical sider disorders that do not reach full criteria for conditions should be ruled out first. As previ- one of primary disorders or have symptoms in ously indicated, specific diagnoses are available only one domain. When full criteria are not met, for these conditions. When mood symptoms are the clinician may, for example, assign a diagnosis present, clinicians must rule out schizoaffective of other specified schizophrenia spectrum and disorder, major depressive disorder with psy- other psychotic disorder. Delusional disorder is chotic features, and bipolar disorder with psy- limited to psychopathology in one of the five chotic features before they can make a diagnosis domains (i.e., only delusions are present), of schizophrenia. Because mood symptoms com- whereas disorders such as schizophrenia require monly occur in schizophrenia, their presence is symptoms in at least two of the five domains. The consistent with the diagnosis and does not auto- next step in the diagnostic process suggested by matically warrant assignment of an alternative the DSM-5 is to consider those diagnoses which diagnosis. For example, a single depressive epi- are time limited. For example, in brief psychotic sode that follows a period of active psychosis is disorder, symptoms must be present for at least entirely consistent with a diagnosis of schizo- 1 day but not more than 30 days. In schizophreni- phrenia. When mood symptoms have occurred or form disorder, symptoms must be present for at are currently occurring, the duration of these least 1 month but not more than 6 months. symptoms and their temporal relationship to psy- Symptoms lasting longer than 6 months typically chotic symptoms are key in making an accurate indicate a diagnosis of schizophrenia or schizoaf- differential. The main differentiation between fective disorder. It is also important to consider schizophrenia, major depressive disorder with level of functional impairment that is associated psychotic features, and bipolar disorder with psy- with symptoms because diagnoses like delusional chotic features is the temporal relationship disorder do not usually present with substantial between mood symptoms and psychotic symp- impairment, while a schizophrenia diagnosis toms. If psychotic symptoms begin after the onset requires marked functional impairment or dis- of manic or depressed symptoms, resolve when tress before diagnosis can be made. the affective symptoms resolve, and only occur Schizophrenia itself is diagnosed when two or when affective symptoms are present, a diagnosis more symptoms are present from the following: of major depressive disorder or bipolar disorder delusions, hallucinations, disorganized speech, should be strongly considered, with the added grossly disorganized or catatonic behavior, and specifier indicating the presence of psychotic negative symptoms. These symptoms must be symptoms. A diagnosis of schizoaffective disor- present for a significant portion of the time since der is made when psychotic symptoms occur the onset of the disorder and must cause marked independently of mood symptoms and the mood functional impairment in major domains such as symptoms are present for most of the illness. work, interpersonal relationships, or self-care. Thus, a detailed history of psychotic and mood Symptoms must be present for at least 6 months symptoms is vital for accurate differential and must not be attributable to a medical condi- diagnosis. tion or substance (e.g., drug). If mood symptoms (depression or mania) are present, they occur only for a minority of the time. Cultural Considerations in DSM-5 Diagnoses Differential Diagnosis of Schizophrenia The main considerations in differential diagnosis of The recognition that psychiatric symptoms may schizophrenia focus on the distinction between not manifest in an identical manner across vari- primary and secondary psychotic disorders and ous cultures or have different cultural meanings ruling out affective disorders when symptoms of led to increased consideration of culture as an 26 Cultural Considerations and Schizophrenia 377 important component of the diagnostic interview loss, which in the Hindu system of medicine is in order to decrease diagnostic errors that are one of the seven essential bodily fluids that needs attributable to patient variability or examiner to be balanced in order to maintain health and bias (Lewis-Fernández et al., 2010). wellness. Acknowledging the importance of cultural influ- Finally, Section III of the DSM-5 con- ence on diagnosis, the DSM-5 included resources tains a detailed Cultural Formulation section designed to help clinicians increase consider- which includes a description of the Cultural ation of various cultural factors. One of these Formulation Interview (CFI). The CFI is a semi- resources is background information for race, structured interview made up of 16 questions gender, and other factors that is provided for that are designed to help clinicians determine each DSM diagnosis (when available), including the degree to which culture influences their cli- the schizophrenia spectrum and other psychotic ents’ clinical presentations or care (APA, 2013). disorders. This information is contained under It utilizes a person-centered approach in order each diagnostic description in clearly marked to avoid stereotyping and is designed for use sections, e.g., Culture-Related Diagnostic Issues with any individual. The APA has made these or Gender-Related Diagnostic Issues. The materials available free of charge in an online DSM-5 also contains an Appendix which is a format at https://www.psychiatry.org/psy- glossary of cultural concepts of distress, which chiatrists/practice/dsm/educational-resources/ has replaced culture-bound syndromes with three assessment-measures. constructs that are hoped to have better clinical Research reporting the importance of cultural utility. The first is the concept of a cultural syn- and ethnic factors in diagnostic assessment con- drome, which is a consistent group of co-occur- tinues to grow (Adebimpe 1981; Al-Issa, 1995; ring symptoms that occur within a culture and Dana, 2008; Paniagua, 2001; Trierweiler et al., may or may not be viewed as an illness. An 2000). It is now understood that because the example is ataque de nervios, which is a syn- clinical interview is an interpersonal interaction, drome that occurs among individuals of Latin clinicians who have increased their cultural sen- decent and involves a sense of being out of con- sitivity through training, self-education, and trol, with intense emotional upset (anxiety, consultation are most effective in accounting for anger, grief), attacks of crying, verbal and physi- the impact of cultural factors on the diagnostic cal aggression, and (at times) dissociative epi- process. There are a number of excellent sodes, fainting or seizure-like episodes, as well resources that discuss cultural factors relevant to as suicidal gestures. The second is the concept of clinical interviewing and diagnosis which cultural idiom of distress which is a way of include socioeconomic status and population expressing distress that may or may not include characteristics, racial identity, racism and dis- specific symptoms, but that provide a shared way crimination, language, and cultural mistrust of discussing personal experiences. For exam- among others (see Zink, Lee, & Allen, 2015). ple, the idiom “nerves” or “depressed” may Others have proposed useful conceptual frame- mean different things in one culture versus works to address diagnostic bias that might arise another culture and may not be descriptive of a from culture-related factors (e.g., Grieger, 2008) specific set of symptoms. The third cultural con- that emphasize fundamental issues such as cul- cept of distress is a cultural explanation, which tural identity, level of acculturation, family is a perceived cause or attribution that serves to structure and expectations, level of racial/cul- explain the symptoms or illness. For example, tural identity development, and immigration Dhat syndrome is used to describe a clinical pre- issues, among others. Some suggest that struc- sentation in males where a myriad of symptoms tured and semi-structured interviews may help might be present (e.g., fatigue, anxiety, weak- reduce diagnostic bias because questions are ness, impotence, etc.), but the etiology of the standardized and uniform clinical information is dysfunction is described as being due to semen gathered, but the extent to which the interviews 378 J. E. 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The illusion of reality or the reality of ongoing goal for clinicians is to increase cultural illusion: Hallucinations and culture. British Journal of awareness regarding the possible influences of Psychiatry, 166, 368–373. American Psychiatric Association. (2013). Diagnostic culture on the clinical interview in order to and statistical manual of mental disorders (5th ed.). reduce diagnostic bias. Arlington, VA: Author. Andreasen, N. C. (1979). Thought, language, and communication disorders: I clinical assessment, definition of terms, and evaluation of their reliability. Archives of Conclusion General Psychiatry, 36, 1315–1321. Andreasen, N. C. (1982). Negative symptoms in Here we presented a comprehensive discussion Schizophrenia: Definition and reliability. Archives of how cultural factors can be considered by of General Psychiatry, 39, 784–788. https://doi. org/10.1001/archpsyc.1982.04290070020005 behavioral health specialists in the differential Andreasen, N. C. (1984). Scale for the Assessment of diagnosis of schizophrenia spectrum disorders. Positive Symptoms (SAPS). Iowa City, IA: University Review of prevalence rates of schizophrenia of Iowa. spectrum disorders across age, gender, and eth- Andreasen, N. C. (1989). Scale for the assessment of negative symptoms (SANS). The British Journal of nicities have shown a complex pattern with con- Psychiatry, 155(Suppl 7), 53–58. flicting evidence for gender, an earlier onset in Barnes, A. (2013). Race and Schizophrenia diagnoses in males, and a higher prevalence rate in African four types of hospitals. Journal of Black Studies, 44, Americans compared to Caucasians. Behavioral 665–681. https://doi.org/10.1177/0021934713506116 Bilder, R. M., Mukhergee, S., & Rieder, R. O. (1985). health specialists are most often in the role of Symptomatic and neuropsychological components of conducting assessments for schizophrenia spec- defect state. Schizophrenia Bulletin, 11, 409–419. trum disorders, and therefore we outlined in Blow, F. C., Zeber, J. E., McCarthy, J. F., Valenstein, M., detail how cultural factors can be considered in Gillon, L., & Bingham, C. R. (2004). Ethnicity and diagnostic patterns in veterans with psychoses. Social all steps of differential diagnosis. In Part II, we Psychiatry & Psychiatric Epidemiology, 39, 841–851. discuss various factors that assist in culturally Bourque, F., van der Ven, E., & Malla, A. (2011). A meta- competent assessment and treatment of analysis of the risk for psychotic disorders among first- schizophrenia. and second-generation immigrants. Psychological Medicine, 41, 897–910. https://doi.org/10.1017/ This chapter addressed a considerable gap in S0033291710001406 the literature by providing a comprehensive Brown, S., Inskip, H., & Barraclough, B. (2000). Causes summary of how cultural factors can be consid- of the excess mortality of Schizophrenia. British ered in the differential diagnosis of schizophre- Journal of Psychiatry, 177, 212–217. Carpenter, W. T., Conley, R. R., Buchanan, R. W., Breier, nia spectrum disorders. Thereby, behavioral A., & Tamminga, C. A. (1995). Patient response and health specialists have a readily accessible resource management: Another view of clozapine resource tool to further their cultural compe- treatment of Schizophrenia. American Journal of tence when working with patients with severe Psychiatry, 152, 827–832. https://doi.org/10.1176/ ajp.152.6.827 mental illness. Carpenter, W. T., Jr., Heinrichs, D. W., & Wagman, A. M. (1988). Deficit and nondeficit forms of Schizophrenia: Acknowledgement We thank Gregory P. Strauss for his The concept. American Journal of Psychiatry, 145(5), helpful comments on this chapter. 578–583. 26 Cultural Considerations and Schizophrenia 379

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Nina B. Paul, Julia E. Maietta, and Daniel N. Allen

Introduction related diagnostic issues including cultural mistrust. Next, selected measures used to assess In the previous chapter on diagnosis and preva- psychotic symptom severity and frequency are lence of Diagnostic and Statistical Manual of discussed including their translation from Mental Disorders fifth edition (DSM-5) (APA, English into other languages, selected psycho- 2013) schizophrenia spectrum and other psy- metric data, and symptom expression across chotic disorders (SSOPD), we reviewed preva- racial and ethnic groups. A brief discussion of lence rates of the disorder across age, gender, and cultural sensitivity when assessing neurocogni- ethnicities, discussed cultural considerations for tion and daily functioning for people with symptom presentation, and considered impact of schizophrenia spectrum disorders is included culture and ethnicity on diagnosis. New knowl- given that neurocognitive deficits are identified edge regarding the importance of cultural factors as a core feature of schizophrenia and func- in the assessment and treatment of schizophrenia tional impairment is common. Last included is spectrum disorders has also emerged over the a review of recommendations to assure fairness past couple of decades, and in this chapter we in testing and assessment. summarize this information to provide a resource The second part of this chapter addresses cul- for behavioral healthcare providers who provide tural factors relevant for treatment of schizo- assessment and intervention services to diverse phrenia spectrum disorders. It begins with populations with schizophrenia spectrum discussing the most recent review on cultural disorders. adaptations of psychosocial treatments for The first part of this chapter addresses cul- schizophrenia that proposed nine common tural factors relevant for assessment of themes of cultural adaptations. Cultural adapta- SSOPD. Structured and semi-structured inter- tions of the seven therapy approaches that views commonly used to arrive at a diagnosis received an evidence-based rating of “strong are summarized, with discussion of culture- support” by the American Psychological Association’s (APA) Division 12 are then reviewed. References are provided for these culturally adapted treatment manuals to aid clini- N. B. Paul · J. E. Maietta · D. N. Allen (*) cians in accessing these resources. The chapter Department of Psychology, University of Nevada, concludes with a general approach that allows Las Vegas, NV, USA e-mail: [email protected]; the integration of cultural factors into any type [email protected] of treatment approach.

Cultural Factors Relevant see Olbert et al., 2018). Because there is abun- for Assessment of Schizophrenia dant evidence that structured and semi-structured Spectrum and Other Psychotic interviews increase diagnostic reliability and Disorders validity by reducing criterion-related error and there is evidence supporting a small decrease in Diagnostic Assessment diagnostic bias with use of structured interview procedures, clinicians should consider using a Culturally informed assessment of psychotic structured approach to diagnostic interviewing. symptoms for SSOPD diagnoses may be facili- The comprehensiveness of any evaluation of tated by the use of validated structured and semi- psychotic symptoms depends on the setting, the structured interviews. Other sources provide clinician’s expertise, and the patient’s presenta- more detailed information regarding general con- tion. The Structured Clinical Interview (fifth edi- siderations in clinical interviewing for diagnostic tion, clinical version; SCID-5-CV; First & and treatment purposes (Allen & Becker, 2019a, Williams, 2016) remains one of the most well- 2019b), so here we emphasize cultural consider- validated structured clinical interviews for diag- ations when using available diagnostic assess- nosing SSOPD and other DSM-5 disorders. The ment procedures. It should be noted that there are SCID-5 has been translated into 15 languages strengths and limitations to these approaches. For (APA, 2018) and has separate versions for example, strengths of structured interviews research and clinical diagnoses. Currently, only include that they ensure the same information is the research version but not the clinician version being gathered across different clients by differ- is available in Spanish (APA, 2018). Besides the ent clinicians, and the information gathered is SCID-5, other semi-structured and structured relevant to standard DSM or ICD diagnoses. As a interviews such as the Diagnostic Interview result, their use improves diagnostic reliability Schedule (fourth version; DIS-IV; Robins, and validity. However, the extent to which they Cottler, Bucholz, & Compton, 1995), the can be modified to address specific cultural fac- Schedule for Affective Disorders and tors and symptom expression is often quite lim- Schizophrenia (SADS; Endicott & Spitzer, ited, and they are also inherently limited when 1978), the Present State Examination (PSE; the diagnostic criteria are not culturally informed. Wing, Birley, Cooper, Graham, & Isaacs, 1967), It is relevant to recognize that although they or the Schedules for Clinical Assessment in improve the reliability and validity of diagnoses, Neuropsychiatry (SCAN; World Health they may not mitigate all diagnostic bias. A Organization, 1994) may also be used. The recent meta-analysis found that use of unstruc- Composite International Diagnostic Interview tured and structured interviews had only a small (CIDI; Kessler & Üstün, 2004) and the Mini effect in reducing increased diagnoses of schizo- International Neuropsychiatric Interview (MINI; phrenia in Black individuals compared to White Sheehan et al., 1998) were developed for cross- individuals (Olbert, Nagendra, & Buck, 2018). cultural assessment purposes and so may be par- Diagnostic bias is one possible explanation for ticularly helpful in decreasing diagnostic bias. this disparity, although the increased rates of More detailed information about these proce- schizophrenia diagnoses in Black individuals dures and cultural considerations regarding their may be due to a number of other factors, such as use can be found in several recent chapters (Allen biases in the diagnostic criteria themselves, & Becker, 2019b; Zink, Lee, & Allen, 2015), and decreased access to care which may lead to interested readers are referred to these resources delays in treatment and more severe symptoms at for additional information. the time of diagnosis, and social factors such as discrimination and poverty that may contribute to Culture-Related Diagnostic Issues The DSM- increased incidence of numerous physical and 5 lists the following culture-related diagnostic mental disorders, including SSOPD (for review issues clinicians should consider when diagnos- 27 Cultural Considerations and Schizophrenia 383 ing schizophrenia spectrum disorders: (1) spiri- populations compared to Caucasian populations tual beliefs (e.g., witchcraft) or religious (Combs et al., 2006; Whaley, 2001). Hence, clini- experiences (e.g., hearing an Angel’s voice) that cians must be aware of the concept of cultural are normative in some cultures may be misinter- mistrust and educate themselves about historic preted as delusions or hallucinations, (2) linguis- and current events that justify cultural mistrust. tic differences in narration that may be For more detailed information on cultural consid- misinterpreted as disorganized speech, (3) cul- erations when assessing symptoms of psychosis, tural differences in emotion expression that may see our chapter in this volume on Prevalence, be misinterpreted as negative symptoms or sup- Symptoms, and Diagnosis. port of other psychotic or mood symptoms, and (4) cultural expression of distress that may be misinterpreted as hallucinations (APA, 2013). Assessment of Psychotic Symptom When coming across a possible symptom of Severity and Frequency delusion with spiritual and religious content with which the clinician is not familiar, a culturally There are a number of measures that are avail- competent clinicians may ask “Is this a common able to assess the severity and frequency of psy- belief in your religion that other members of your chotic symptoms. Table 27.1 shows a selection community also hold?” If the answer is “yes,” of measures which are most commonly used for then there should be considerable doubt as to populations with psychotic symptoms to assess whether it truly represents a psychotic symptom. severity and frequency of symptoms as well as If a clinician is still not sure whether possible impairment in neurocognition and daily func- psychotic symptoms are better understood in the tioning. The Positive and Negative Syndrome context of cultural factors, then the diagnosis Scale (PANSS; Kay, Fiszbein, & Opler, 1987) should be postponed until colleagues, spiritual or and newer measures such as the Brief Negative religious leaders, or members of the community Symptom Scale (BNSS; Kirkpatrick et al., can be consulted and help with diagnostic clarifi- 2011) and the Clinical Assessment Interview cation (Sue & Sue, 2016). for Negative Symptoms (CAINS; Kring, Gur, Blanchard, Horan, & Reise, 2013) have been At every level of assessment, it has been sug- translated into Spanish. The BNSS and CAINS gested that clinicians consider cultural mistrust represent new-generation assessment when treating people with severe mental illness approaches for negative symptoms of schizo- from cultural backgrounds that differ from the phrenia that were based on the 2005 Consensus cultural background of the treatment provider Development Conference on Negative (Gurak, Maura, de Mamani, de Andino, & Symptoms sponsored by NIMH (Kirkpatrick Rosenfarb, 2018). In this context, cultural mis- et al., 2006). They include items that assess five trust describes trusting people from other cultural symptom domains identified at the conference: backgrounds less than people who share the same anhedonia, avolition, asociality, blunted affect, cultural background with oneself. Cultural mis- and alogia. These newer rating scales are pre- trust has been found to be related to decreased ferred over older scales. Other commonly used help seeking behavior, preferences for clinicians measures, such as the Scale for the Assessment from the same cultural background, and compe- of Positive Symptoms (SAPS; Andreasen, tency beliefs about clinicians (David, 2010; 1984) and the Scale for the Assessment of Townes, Chavez-Korell, & Cunningham, 2009; Negative Symptoms (SANS; Andreasen, 1982), Whaley, 2001). There is some research to suggest have not been translated into Spanish. that clinicians may misinterpret expression of Considering that Spanish is the second most cultural mistrust by African Americans as para- spoken language in the United States, more noia, which may further contribute to the higher research on measures translated into Spanish is diagnosis of schizophrenia in African-American required. 384 N. B. Paul et al.

0.88 0.80–0.84 0.68–0.74 – 0.75–0.88 – 0.86 0.42 0.46 Concurrent validity – 0.83–0.92 0.91 0.86–0.93 0.89–0.96 0.86–0.97 0.67–0.94 0.97 – 0.91 – – Inter-rater Inter-rater reliability 0.69–0.94 0.65–0.93 0.50–0.91 Scale for the Assessment of SANS Scale for the – – – – – 0.48–0.89 0.75 0.91 0.96 Test-retest Test-retest reliability – – – 0.89 0.93 0.98 0.74–0.88 0.93 – – 0.88 0.90 Internal reliability 0.73–0.83 – – ); Norman Fichman 1982 Oliveira, de Farias de Farias Oliveira, Gómez et al. ( 2015 ) et al. ( 1996 ) No Spanish translation English/Kirkpatrick et al. ( 2011 ) Spanish/Mané et al. ( 2014 ) English/Kring et al. ( 2013 ) Spanish/Valiente- English (Spanish translation uses English norms) English/Becattini- Campos, de Dutra, de Oliveira Araujo, and Charchat- Goldman, ( 2018 ); Patterson, McKibbin, Hughs, and Jeste ( 2001 ) Brazil/Mantovani, Spanish- Brazil/Mantovani, Machado- ( 2015 ) de-Sousa, and Salgado Spanish- Spain/Garcia- Portilla et al. ( 2014 ) English or Spanish language/study ); Kay, English/Kay et al. ( 1987 ); Kay, and Lindenmayer ( 1988 ) Opler, Spanish/Kay, Spanish/Kay, Fiszbein, Herne, Vital- and Fuentes ( 1990 ) English/Norman, Malla, Cortese, and Diaz ( 1996 ) No Spanish translation English/Andreasen ( Scale for the Assessment of Positive Symptoms (Andreasen, 1984 ), Assessment of Positive SAPS Scale for the 2 3 8 1 9 23 Number of translations 50 Scale Scale Performance-based Performance-based Type of measure Type Scale Scale Scale Negative Negative symptoms Negative Negative symptoms Cognitive Cognitive domains Functioning Constructs Positive and Positive negative symptoms Positive Positive symptoms Negative Negative symptoms Translations of measures for schizophrenia spectrum disorders including psychometric properties of English and Spanish versions of measures for schizophrenia spectrum disorders including psychometric properties English and Spanish versions Translations ; Nuechterlein et al., 2008 ), 2008 ; Nuechterlein et al., et al., Battery (Kern Cognition in Schizophrenia Consensus Cognitive Research to Improve Treatment Measurement and MATRICS 2010 ), BNSS CAINS MATRICS UPSA Measure PANSS SAPS SANS Positive and Negative Symptoms Scale (Kay et al.,1987 ), and Negative Positive PANSS UCSD Performance-based Skills Assessment (Patterson et al., 2001 ) Assessment (Patterson UPSA UCSD Performance-based Skills Clinical Assessment Interview for Negative Symptoms (Forbes Symptoms (Forbes for Negative Assessment Interview 2011 ), CAINS Clinical Symptom Scale (Kirkpatrick et al., Symptoms (Andreasen, 1982 ), BNSS Brief Negative Negative et al., Table 27.1 Table 27 Cultural Considerations and Schizophrenia 385

Symptom Expression Across Racial/Ethnic symptoms are represented as a unitary domain Groups A recent review has suggested that the for Caucasian Americans but are represented as high prevalence of schizophrenia spectrum disor- two domains (one representing diminished ders among ethnic minorities may be at least expression and one representing motivation and partly explained by factors such as differences in pleasure) for African Americans (Strauss & symptom expression across ethnic and racial Culbreth, 2015). In conclusion, knowing about groups (Schwartz & Blankenship, 2014) rather these cultural variations may assist clinicians in than diagnostic bias. This suggestion is consis- arriving at a culturally informed diagnosis in tent with the literature that indicates cultural order to provide appropriate treatment. groups express different patterns and severity of symptoms (Gurak et al., 2018). For example, one of the pioneering studies in this field has found Assessment of Neurocognition that African Americans present with more severe and Functional Impairment positive symptoms of psychosis (such as auditory in Schizophrenia Spectrum Disorders hallucinations, thought withdrawal or insertion, thought broadcasting, delusional perception) The Measurement and Treatment Research to which resulted in more frequent diagnoses of Improve Cognition in Schizophrenia Consensus schizophrenia and less frequent diagnoses of Cognitive Battery (MATRICS; Kern et al., 2008; depression with psychotic features (Arnold et al., Nuechterlein et al., 2008) is a neuropsychologi- 2004; Strakowski et al., 1996). In comparison, cal assessment battery developed for assessment Caucasian Americans express more persecutory of cognitive changes in schizophrenia resulting delusions than African Americans (Strakowski from the effects of medication. The battery was et al., 1996) and Mexican Americans (Weisman derived based on expert consensus, incorporating et al., 2000). Interestingly, regarding schizophre- existing neuropsychological tests that had strong nia spectrum disorders, Mexican Americans have validity and reliability evidence when used to been found to be more likely to report physical assess individuals with schizophrenia. It assesses symptoms than Caucasian Americans (Weisman various cognitive domains including processing et al., 2000). There is further evidence from a speed, attention/vigilance, working memory, rea- recent large-scale study with a nationally repre- soning and problem-solving, as well as social sentative sample of African Americans, Asians, cognition. It has been translated into more than Caribbean Blacks, and Latinos living in the 20 languages and is used internationally in many United States that Latinos endorse delusions of settings (these translations use English norms). reference and thought insertion/withdrawal sig- The development of the norms relied on patient nificantly more often than African Americans and community samples from rural and urban and that African Americans are significantly less settings that were representative of the US popu- likely to endorse visual hallucinations but signifi- lation regarding age, sex, racial and ethnic back- cantly more likely to endorse auditory hallucina- ground, and education level (Kern et al., 2011). tions compared to Caribbean Blacks (Earl et al., Hence, its norm-based approach may be consid- 2015). Regarding negative symptoms, however, ered culturally sensitive. It is commercially avail- several studies have found no differences when able, and more information can be obtained on comparing African Americans, Caucasian the publishers website (https://www.parinc.com/ Americans, and Latino Americans (Dassori et al., Products/Pkey/225). 1998; Weisman de Mamani & Caldas, 2013). The Assessment of functioning in daily activities structure of negative symptoms appears stable such as managing finances, making appoint- across cultures when newer measures of negative ments, or shopping may also be required in cer- symptoms are examined (Ahmed et al., 2019), tain settings. The UCSD Performance-based although factor analytic results for older mea- Skills Assessment (UPSA; Patterson et al., 2001) sures such as the SANS indicate that negative is an assessment procedure to evaluate functional 386 N. B. Paul et al. impairment in schizophrenia spectrum disorders. groups (Boone, Victor, Wen, Razani, & Pontón, As its name suggests, the UPSA requires 2007). Efforts have also been directed at explor- completion of certain tasks that are essential to ing how bias in the testing procedure itself can adaptive functioning in real-world setting, and so influence differences in neuropsychological per- it differs from other assessment procedures that formances between cultural groups (for review use self-report or informant-report to judge func- see Afolabi, 2014). The American Psychological tioning. The UPSA has been translated into Association’s Standards for Educational and Spanish. In support of Spanish translations of Psychological Testing (2014) suggest that fair- measures of everyday functioning, a study has ness in testing can be promoted by (1) treating found no differences for monolingual Spanish the test taker fairly during testing, (2) avoiding speakers, Latino English speakers, and non- measurement bias, (3) providing access to mea- Latino English speakers who completed the sured constructs, and (4) individualizing inter- assessment in their native language (Bengoetxea, pretation of test scores. Melikyan, Agranovich, Burton, Mausbach, Patterson, & Twamley, 2014). and Puente (2019) further suggest that fairness Also, there is support that Caucasian raters do not in psychological testing can be improved by (1) show an ethnic/racial bias when rating everyday selecting the most valid test for a minority client functioning among African Americans, by considering test constructs, test procedures, Caucasian, and Latino patients (Sabbag et al., and stimulus materials, (2) asking diagnostic 2015). Lower performance on measures of every- questions to determine which norms are the most day functioning among patients from ethnic/ appropriate for the individual case (researching racial minority backgrounds is related to lower whether norms for minority groups are available levels of education and equivalent levels of cog- and valid), (3) assessing level of acculturation nitive performance (Sabbag et al., 2015). and assimilation to consider test wiseness and Adjusting UPSA results for the influence of edu- level of performance on tests, (4) determining cation and acculturation eliminated differences the language in which the assessment should be between Latino and non-Latino patients conducted and considering that some unintended (Mausbach, Tiznado, Cardenas, Jeste, & or atypical responses may be due to language, Patterson, 2016). and (5) approximating the socioeconomic status and quantity/quality of education to account for

Fairness in Testing Differences in performance test wiseness and test performance. on personality, intellectual and neurocognitive tests are widely reported across cultural groups Thus, when conducting an evaluation with a and have led to controversial opinions such as Spanish or Chinese client, for example, one may that intelligence inherently differs between eth- choose to administer the MATRICS in Spanish or nic and racial groups (Herrnstein & Murray, Chinese and utilize norms from a Spanish 1994). Such opinions have been rebutted over (Rodriguez-Jimenez et al., 2012) or Chinese (Shi the past several decades (for review see Ma and et al., 2015) representative sample. Also, clini- Schapira, 2017) and promoted discussion and cians who are not fluent in the language of the research into racial or ethnic factors that may test taker should perform the assessment with an unfairly bias test results. Thus, in this context, interpreter present or refer to a clinician who is fairness in testing refers to diminishing the fluent in the test taker’s language. Yet, beyond impact of variance in test performance that is not these decisions, each individual case still requires related to the construct that is being measured, clinical expertise to judge other factors such as but rather results from individual or cultural dif- whether test constructs measured by the ferences. There has been in-depth exploration MATRICS are valued in the clients’ culture (e.g., that also considers factors such as language and in Eastern cultures quality of work is often val- acculturation contributing to differences in psy- ued over speed), whether the client has accultur- chological test performance among cultural ated/assimilated to a new culture and in this 27 Cultural Considerations and Schizophrenia 387 culture gained testing experience and possibly Nine Common Themes of Cultural test wiseness, or whether the clients’ quality of Adaptations of Psychosocial education justifies the education-based correc- Interventions for Psychosis tion of performance scores. In conclusion, we advise the reader to treat the information on cul- Degnan et al. (2018) conducted a systematic turally sensitive measures discussed in this chap- review and meta-analysis of culturally adapted ter only as foundational knowledge but use psychosocial interventions for psychosis. Their clinical expertise, consultation, and existing review included studies on culturally adapted research to arrive at optimal treatment decisions CBT, social skills training, family psychoeduca- on a case-by-case basis. tion, family interventions, combined interventions, and illness management and recovery programs. They summarized that cultural adapta- Cultural Factors Relevant tions for psychosocial interventions of schizo- for Treatment of Schizophrenia phrenia can be grouped according to the following Spectrum and Other Psychotic nine themes: (1) language (direct translation into Disorders national language, incorporation of local dialect), (2) concepts and illness models (culture-specific Cultural factors should be considered in behav- explanatory models, focus on mental health ioral treatments for SSOPD. In the following sec- stigma, acknowledgment of low mental health tions, we discuss a recent review on cultural knowledge and education level), (3) family adaptations of psychosocial treatments for (importance of family involvement, culture- schizophrenia which identified nine common specific family structures, culture-specific family themes of cultural adaptations. Next, we intro- roles and responsibilities), (4) communication duce the seven therapy approaches that received a (cultural differences in openness and disclosure, rating of “strong support” by APA’s Division 12 culture-specific strategies of conflict resolution and review cultural adaptations for each. Last, we and problem-solving, culture-specific ways of discuss a general approach of how consideration teaching and learning), (5) content (addition of of cultural factors may be integrated into any culture-relevant content, removing of culturally kind of treatment approach. irrelevant content), (6) cultural norms and prac- Of note, pharmacological treatment remains tices (culture-specific practices and coping meth- the first-line treatment for SSOPD (Miyamoto, ods, culturally relevant activities and scenarios, Miyake, Jarskog, Fleischhacker, & Lieberman, enhancing community and social networks), (7) 2012). For this reason, behavioral health special- context and delivery (location of intervention, ists should regularly consult with their patients’ flexibility in scheduling sessions, intervention psychiatrists or prescribing medical healthcare mode, length of intervention), (8) therapeutic providers to be informed about their patients’ alliance (therapist and client matched for charac- current medications. Behavioral healthcare pro- teristics, therapist’s cultural competency training, viders may also refer patients to prescribing med- adapting therapeutic approach), and (9) treatment ical healthcare providers in the community if goals (intervention goals and outcome). Their their patient’s pharmacological needs have not meta-analysis results concluded that culturally yet been met. Since medication management is adapted psychosocial treatments were more effi- often a challenge for patients with severe mental cacious than treatment as usual regarding symp- illness, behavioral strategies such as medication tom severity, positive symptoms, and general logs to assist with compliance may be beneficial symptoms. Moreover, the degree of cultural (Eckman, Liberman, Phipps, & Blair, 1990). adaptation predicted symptom improvement. 388 N. B. Paul et al.

There is a paucity of literature regarding psy- Society of Clinical Psychology (Division 12) chosocial treatments of SSOPD for children and ascribes “strong support” to the following adolescents (Stafford et al., 2015) which is likely evidence-based treatments for schizophrenia and related to onset of psychotic symptoms before severe mental illness: cognitive behavioral ther- adolescence being rare (APA, 2013). Yet, consid- apy, social skills training, family psychoeduca- ering literature on first-onset psychosis and adult tion, social learning/token economy programs, psychosis, recommended treatments for youth cognitive remediation, supported employment, include cognitive behavioral therapy, social and assertive community treatment (for more skills, multifamily group therapy, and some information regarding Division 12’s strongly briefer forms of cognitive rehabilitation training supported evidence-based treatments, visit as well as an integration of supported vocational https://www.div12.org/diagnosis/schizophrenia- or academic programs (Baker, Howell, & and-other-severe-mental-illnesses, APA, 2016). Findling, 2016). We briefly describe each of these treatments and their cultural adaptations (if any) below. See Table 27.2 for a list of resources of English mate- Culturally Adapted Evidence-Based rials and culturally adapted treatments. Behavioral Treatments Cognitive Behavioral Therapy for Psychosis Based on criteria proposed by Chambless and (CBTp) Similar to cognitive behavioral therapy Hollon (1998) for empirically supported thera- (CBT) for other diagnoses, CBT for psychotic pies, the American Psychological Association’s disorders (CBTp) involves fostering a working

Table 27.2 Cultural adaptations of evidence-based therapies for schizophrenia spectrum disorders Therapy English resources recommended by APA Cultural adaptation resources Cognitive behavioral Cognitive Behavioral Therapy for CBT for Psychosis translated for Mexican therapy for psychosis Schizophrenia (Kingdon & Turkington, patients (Zimmer, Duncan, Laitano, (CBTp) 1994) and Cognitive Therapy for Ferreira, & Belmonte-de-Abreu, 2007) Schizophrenia (Kingdon & Turkington, CBT for Psychosis translated for Chinese 2005) patients (Li et al., 2015) Cognitive Therapy for Delusions, Voices Culturally Adapted CBT for Psychosis and Paranoia (Chadwick, Birchwood, & (CA-CBTp) for Egyptian patients (Naeem Trower, 1996) et al., 2015) Metacognitive Training (MCT) for Indian patients (Kumar et al., 2010) Social skills training Social Skills Training for Schizophrenia Skills Training (ST) adapted for Mexican- (Bellack, Mueser, Gingerich, & Agresta, American, other Central American, and 2004) Caribbean patients (Kopelowicz, Zarate, Social Skills Training for Psychiatric Smith, Mintz, & Liberman, 2003) Patients (Liberman, Derisi, & Mueser, Psychosocial Skills Training (PSST) 2001) adapted for Mexican patients (Valencia et al., 2010) Social Cognitive Skills Training (PEDAL) adapted for Latino patients (Mausbach et al., 2008) Chinese Basic Conversation Skills Module (CBCSM) adapted for Chinese patients (Lak, Tsang, Kopelowicz, & Liberman, 2010) Social Cognition and Interaction Training (SCIT) adapted for Chinese patients (Wang et al., 2013) Social Skills Training adapted for Chinese patients (Weng, Xiang, & Lieberman, 2005) Social Cognitive Skills Training (SCST) adapted for Egyptian patients (Gohar, Hamdi, Lamis, Horan, & Green, 2013) (continued) 27 Cultural Considerations and Schizophrenia 389

Table 27.2 (continued) Therapy English resources recommended by APA Cultural adaptation resources Family Family Psychoeducation Resource Kit Multiple-Family Group Treatment (MFGT) psychoeducation (Substance Abuse and Mental Health for Vietnamese patients (Bradley et al., 2006) Service Administration, SAMHSA, 2010a) Family Intervention for Schizophrenia Multifamily Groups in the Treatment of adapted for Italian patients (Carrà, Severe Psychiatric Disorders (McFarlane, Montomoli, Clerici, & Cazzullo, 2007) 2002) Family Education (FE) for people with Family Care of Schizophrenia (Falloon, Schizophrenia adapted for Chinese patients Boyd, & McGill, 1984) (Li & Arthur, 2005; Ran et al., 2003) Psychoeducational Family Intervention adapted for Chinese patients (Xiang, Ran, & Li, 1994) Group Psychoeducation of Relatives of Schizophrenic Patients, adapted for Chinese patients (Zhang & Yan, 1993) Family-based Intervention for Schizophrenic patients, adapted for Chinese patients (Xiong et al., 1994) Multiple-Family-Group Intervention for Chinese families of patients with Schizophrenia (Chien & Chan, 2004) Family Intervention for Schizophrenia adapted for Iranian patients (Koolaee & Etemadi, 2010) Psychoeducational Intervention for Caregivers of Indian patients (Kulhara, Chakrabarti, Avasthi, Sharma, & Sharma, 2009) Psychoeducational Group Program, adapted for Korean American patients (Shin & Lukens, 2002) Social learning/token Treatment and Rehabilitation of Severe None found in our literature search economy programs Mental Illness (Spaulding, Sullivan, & Poland, 2002) The Token Economy (Ayllon & Azrin, 1968) Cognitive remediation Training Program for the Remediation of Cognitive Rehabilitation for Schizophrenia Cognitive Deficits in Schizophrenia adapted for Korean patients (Lee & Lee, (Delahunty & Morice, 1993) 2017) Remediation of Cognitive Deficits in Cognitive Rehabilitation for Schizophrenia Psychiatric Patients (Medalia, Revheim, & adapted for Brazilian patients (Pontes et al., Herlands, 2002) 2013) Cognitive Remediation Therapy for Schizophrenia (Wykes & Reeder, 2005) Supported A Working Life for People With Severe Supported Employment Program adapted employment Mental Illness (Becker & Drake, 2003) for Latino Americans (Mueser et al., 2014) Supported employment implementation resource kit draft (SAMHSA, 2010b) Assertive community Assertive community treatment Assertive Community Treatment for treatment implementation resource kit draft Persons with Severe Mental Illness adapted (SAMHSA, 2008) for ethnic minority groups (Yang et al., Assertive outreach in mental health (Burns 2005) & Firn, 2002) Assertive Community Treatment of Persons with Severe Mental Illness (Stein, 1998) 390 N. B. Paul et al. alliance, providing psychoeducation and normal- ment length was limited to six sessions to over- ization, and a case formulation and treatment come the barrier of geographical distance to the plan that consider the interplay of thoughts, feel- treatment facility. An additional session for the ings, and behaviors (APA, 2016). In addition, whole family and the involvement of a carrier CBTp may include setting goals that specifically throughout treatment acknowledged the impor- address psychotic symptoms such as learning tance of family in Pakistani culture. This treat- how to reattribute, understanding the content of, ment showed significantly greater improvement and using coping strategies for hallucinations; in overall symptomatology, positive symptoms, assessing antecedents and consequences of delu- negative symptoms, and insight when compared sions and generating alternatives; or working on to treatment as usual (Naeem et al., 2015). These negative symptoms in the short and long term examples speak to the success of translating and (Kingdon & Turkingdon, 2005). The overarching culturally adapting CBTp for the use in countries treatment goal is typically to help patients man- outside the United States, yet future studies are age their symptoms, decrease personal distress, needed that develop and assess cultural adapta- and improve functioning in daily life (APA, tions for the use of culturally diverse patient pop- 2016). There is much meta-analytic evidence ulations residing within the United States. supporting the efficacy of CBTp (Burns, Erickson, & Brenner, 2014; Hazell, Hayward, Social Skills Training (SST) for Cavanagh, & Strauss, 2016; Turner, van der Schizophrenia Social skills training (SST) for Gaag, Karyotaki, & Cuijpers, 2014). There is psychotic disorders is usually conducted in also evidence for the efficacy of translations and groups and involves therapists modelling social cultural adaptations of CBTp. A cognitive behav- skills broken down into concrete steps as well as ioral program translated for the use with Mexican patients learning the skills in role-plays with patients showed significantly greater positive other group members and repeatedly practicing effects on cognitive variables, social-occupational the skills (APA, 2016). Specific social skills exer- functioning, and quality of life compared to treat- cises may relate to conversing with others, being ment as usual (Zimmer et al., 2007). CBTp trans- assertive, managing conflict, living with others, lated for use with Chinese patients was found to interacting with friends and romantic partners, be significantly more efficacious than supportive managing health-related situations, functioning therapy for reduction of overall symptomatology, in work situations, or coping with drug and alco- positive symptoms, and social outcomes func- hol use (Bellack et al., 2004). There is meta- tioning (Li et al., 2015). Further, metacognitive analytic evidence of the efficacy of SST related to training (MCT), a variant of CBT, translated for improvement of general psychotic psychopathol- the use with Hindi-speaking patients showed a ogy and specifically of negative symptoms greater decline in positive symptoms with (Turner et al., 2017). There are also several stud- medium to large effect sizes compared to treat- ies that support the efficacy of culturally adapted ment as usual (Kumar et al., 2010). SST for Spanish-speaking patients including Latino-American patients (Kopelowicz et al., Naeem et al. (2015) went beyond translating 2003; Mausbach et al., 2008) and Mexican CBTp by also incorporating the following cul- patients (Valencia et al., 2010; Valencia, Rascón, tural adaptations for the use with Pakistani Juárez, & Murow, 2007). Further, there are stud- patients: (1) inclusion of a spiritual dimension in ies that support SST programs culturally adapted case formulation and treatment plan, (2) usage of for the use with Chinese patients (Lak et al., Urdu equivalents of CBT jargons in therapy, (3) 2010; Weng et al., 2005). Interestingly, the Social development of culturally appropriate homework Cognition and Interaction Training (SCIT), a assignments, and (4) incorporation of folk stories relatively new variant of social skills training that and examples related to local religious beliefs to considers recent research on social cognition in explain therapeutic concepts. Importantly, treat- individuals with psychotic disorders, adapted for 27 Cultural Considerations and Schizophrenia 391 the use with Chinese patients showed significant Overall, social skills trainings for psychotic dis- improvement in emotion perception, theory of orders have been adapted broadly for culturally mind, social functioning, and attributional style diverse clients and in general appear to be well compared to no treatment (Wang et al., 2013). suited to be adjusted to individual patients by Translating a similar cognitive skills training incorporating personally relevant examples of (SCST) program into Arabic for Egyptian social situations. patients also led to significant improvement in identifying emotions and managing emotions and Family Psychoeducation for Schizophrenia overall emotional intelligence compared to the Family psychoeducation for schizophrenia control condition (Gohar et al., 2013). involves treatment models that include family members in interventions. The goals of this type In addition to straightforward translation of of treatment are to decrease the family’s burden, existing manuals and stimuli, these studies also increase family communication and improve employ more complex and creative methods. For relationships, as well as reduce distress of family instance, Kopelowitz, Zarate, Smith, Mintz, and members. Psychoeducation includes aspects of Liberman (2003) attempted to create a “universal education about crisis intervention, general infor- Spanish” that could be understood by Spanish- mation about schizophrenia, help with family speaking patients from different backgrounds by problem-solving, support, and family communi- considering various Latino dialects and colloqui- cation training. Family psychoeducation pro- alisms and focusing on Spanish vocabulary at the grams have been shown to reduce relapse rates, elementary school level. Videos presenting social benefit the family’s well-being, and improve modelling examples were substituted by in- recovery for patients with schizophrenia (Dixon session modelling (Valencia et al., 2010), by per- et al., 2001; Jewell, Downing, & McFarlane, formances by local actors (Lak et al., 2010), or by 2009; McFarlane, Dixon, Lukens, & Lucksted, newly made videos (Wang et al., 2013). 2003). Because schizophrenia typically causes The abovementioned studies went beyond significant functional impairment, burden on translation efforts and additionally included vari- family members is a common occurrence (Awad ous cultural adaptations. Adaptations to Latino & Voruganti, 2008). There are, of course, cultural culture focused on creating a sense of personal- differences in regard to the importance of family ismo (i.e., importance of a personal connection on an individual. In fact, one study found that as with others) by including a time for platica (small many as 60% and 75% of African-American and talk) in the beginning or end of sessions, having Latino patients (respectively) lived with their therapists offer appropriate self-disclosure, or family, as compared to 30% of White patients sharing food (Kopelowicz et al., 2003; Valencia with schizophrenia (Guarnaccia, 1998). et al., 2010). Adaptations to Chinese culture involved changing examples of social situations There is an abundance of literature discussing from Western culture to Eastern culture—for cultural adaptations of family psychoeducation instance, changing an example of a party situa- for schizophrenia that takes into account spiri- tion to an example of a “yum cha,” a tea gathering tual, linguistic, and other cultural contextual fac- at a restaurant (Lak et al., 2010). Cultural adapta- tors. Indeed, some families (especially those that tions for Egyptian and Arabic culture involved have more collectivistic family values) prefer to excluding stimuli that depicted unfamiliar recre- care for their family member with schizophrenia ational activities such as drinking alcohol or at home rather than have them reside in inpatient playing American football (Gohar et al., 2013). treatment facilities, and so psychoeducation can Moreover, in culturally adapted programs for greatly benefit these groups (Chien, 2008; both Latino and Chinese patients, family mem- Khoshknab, Sheikhona, Rahgouy, Rahgozar, & bers were involved in therapy (Kopelowicz et al., Sodagari, 2014). Language of psychoeducation 2003; Valencia et al., 2010; Weng et al., 2005). has demonstrated benefits for post- 392 N. B. Paul et al. psychoeducation symptom reduction as well as nitive deficits (such as executive function, mem- family coping and reduction in caregiver burden ory, processing speed, and attention) cause in (Barrio & Yamada, 2010; Cheng & Chan, 2005; patients with schizophrenia, cognitive remedia- Kopelowicz et al., 2012). Family psychoeducation treatment for schizophrenia works to improve tion approaches for schizophrenia have been these cognitive abilities through cognitive train- adapted for Chinese (Chien & Chan, 2013; Li & ing. This treatment modality is typically very Arthur, 2005; Ran et al., 2003; Zhang, He, time-limited and can include both computerized Gittelman, Wong, & Yan, 1998), Korean and paper-and-pencil cognitive tasks. While this American (Shin & Lukens, 2002), and Iranian treatment presents a theoretically sound basis for patients (Koolaee & Etemadi, 2010). Spirituality managing impairment associated with schizo- has been shown to be associated with lower nega- phrenia, effects are moderate for cognitive ability tive symptoms (Shah et al., 2011), and religious improvement and small for symptom reduction methods of coping have also been shown to pro- (McGurk, Twamley, Sitzer, McHugo, & Mueser, duce good outcomes for symptom reduction and 2007; Wykes, Huddy, Cellard, McGurk, & coping as well as family coping with schizophre- Czobor, 2011). When combined with psychiatric nia (Mohr et al., 2011; Murray-Swank et al., rehabilitation (or psychosocial intervention to 2006; Revheim, Greenberg, & Citrome, 2010; improve community functioning and well-being), Rosmarin, Bigda-Peyton, Öngur, Paragament, & outcomes improved (McGurk et al., 2007; Wykes Björgvinsson, 2013; Tabak & Weisman de et al., 2011). It is unclear whether these cognitive Mamani, 2014; Weisman de Mamani, Weintraub, training tasks cause sustained ability improve- Gurak, & Maura, 2014). Lopez, Kopelowicz, and ment. Research regarding combined treatment Cañive (2002) present strategies for adapting with cognitive remediation has demonstrated family psychoeducation interventions for Latino some support for the use of functional skills groups. Lefley (2009) describes family psycho- training (Bowie, McGurk, Mausbach, Patterson, educational practices from around the world. & Harvey, 2012), supported employment (Bell, Choi, Dyer, & Wexler, 2014), and vocational Social Learning/Token Economy Programs rehabilitation (Ullevoldsæter Lystad et al., 2017). for Schizophrenia Social learning and token In general, cognitive remediation alone does not economy programs for psychotic disorders are make a significant impact on functional outcomes typically used in inpatient or residential facilities for schizophrenia; however, when combined with and involve rewarding adaptive/appropriate other forms of treatment, robust improvements behaviors (e.g., treatment participation, medica- can occur. Only two cultural adaptations were tion adherence, self-care, or vocational activities, found for cognitive remediation that included use among others) with rewards (e.g., tokens or of linguistically appropriate cognitive remedia- points) (APA, 2016). A recent review on token tion exercises (Lee & Lee, 2017) and use of sim- programs for psychotic disorders concluded that pler and more affordable (e.g., noncomputerized) while studies provide support for the efficacy of methods of service delivery for a developing these programs, most studies are restricted by country (Pontes et al., 2013). Adaptations that methodological flaws and the historical context should be investigated in the future include of when they were conducted decades ago changes in the use of language of administration (Dickerson, Tenhula, & Green-Paden, 2005). Our of cognitive training tasks. literature review did not find cultural adaptations of social learning and token economy programs Supported Employment for Schizophrenia for psychotic disorders. Supported employment programs for patients with psychotic disorders integrate vocational

Cognitive Remediation for Schizophrenia Due rehabilitation and mental health programs and to the significant functional impairment that cog- focus on job placement in the community and 27 Cultural Considerations and Schizophrenia 393 continued individualized job development and patients; Rosenheck & Dennis, 2001). Indeed, a support (APA, 2016). There are various studies recent meta-analysis reported that ACT is sig- supporting the effectiveness of supportive nificantly better than traditional case manage- employment approaches for patients with severe ment models of treatment for homeless mental illness (Bond, Drake, Meuser, & Becker, individuals with schizophrenia (Coldwell & 1997; Drake, Becker, Biesanz, & Wyzik, 1996; Bender, 2007). There is some debate about ACT Drake et al., 1999; Lehman et al., 2002). A recent in the literature because while many patients study found that Latino-American patients in a report being satisfied with ACT (44%, Gerber & supportive employment program had better com- Prince, 1999), some clinicians and researchers petitive job outcomes compared to Latino- cite ethical issues with some aspects of ACT American patients in standard services or (i.e., confidentiality, coercion through the use of clubhouse programs, and overall supported legal methods to ensure medication compliance, employment programs produced comparable and privacy; Szmukler & Holloway, 1998) that rates of competitive work for Latino-American, has been explored in the literature with inconsis- African-American, and non-Latino patients tent findings regarding feelings of coercion and (Mueser et al., 2014). Adaptations of supportive treatment outcomes (Galon & Wineman, 2011; employment programs for psychotic disorders Jaeger & Rossler, 2010; Lamberti et al., 2014; targeting patients who have experienced a first Stanhope, Marcus, & Solomon, 2009). psychotic episode (Nuechterlein et al., 2010), Qualitative evidence suggests that coercive patients that are middle-aged or older (Twamley, means of treatment compliance may serve as a Narvaez, Becker, Bartels, & Jeste, 2008), and barrier to accessing healthcare (Hughes, patients that live in rural areas (Gold et al., 2006) Hayward, & Finlay, 2009; Swartz, Swanson, & also report positive results. Supportive employ- Hannon, 2003). There is currently no quantita- ment approaches have been adopted for countries tive evidence that the use of legal methods to other than the United States including Australia ensure medication and treatment compliance in (Killackey, Jackson, & McGorry, 2008), Canada schizophrenia leads to negative outcomes; how- (Corbière, Bond, Goldner, & Ptasinski, 2005), ever, the issue remains debated in many profes- Hong Kong (Kin Wong et al., 2008), Japan (Sato sional circles. et al., 2014), and several European countries (Fioritti et al., 2014). Regarding cultural adaptations for ACT, there was only one study citing specific adaptations Assertive Community Treatment (ACT) for that were evidence-supported (Yang et al., 2005). Schizophrenia ACT is a community-based, This study utilized matching ACT team members multidisciplinary treatment program that works to patients who were linguistically diverse (e.g., to keep patients with schizophrenia out of the English was not their native language), which hospital by attending to community factors that resulted in a significant reduction in hospitaliza- might make them vulnerable to rehospitalization tions and symptoms (Yang et al., 2005). The use (Scott & Dixon, 1995; Stein & Test, 1980). ACT of linguistic matching as well as culturally rele- team members may include psychiatrists, psy- vant social programming to enhance community chologists, and other behavioral health profes- integration (e.g., Chinese noodle group, yoga sionals who share a caseload and have frequent classes, etc.) and legal resources that may benefit contact with patients. ACT teams assist with cultural groups specifically (e.g., refugee claims, medication management, social service delivery immigration issues) were supported in this study and connection to resources, as well as rehabili- (Yang et al., 2005). Although no other studies cit- tation. ACT is particularly useful for those indi- ing specific cultural adaptations for ACT were viduals who have difficulty remaining in found, the Department of Human Services in traditional outpatient settings (e.g., homeless Minnesota created a resource implementation 394 N. B. Paul et al. guide that provides case examples integrating to one’s culture or identity; (7) unemployment cultural competence into ACT service delivery and economic stress related to immigrant status (Minnesota Department of Human Services, or cultural orientation; and (8) immigration stress 2002). including problems with legal status, deportation, and social isolation. These types of cultural interviews can easily be added on to other evidence- General Approach of Integrating based treatment modalities. In long-term Ethnic and Cultural Background behavioral treatment, instruments of cultural fac- Considerations tors may be divided up over several sessions and can clearly add much value to the process and the The review of culturally adapted evidence-based outcome of therapy. treatment approaches above hints at the challenges inherent in adapting every treatment for every likely combination of cultural factors. Conclusion Practicing clinicians may require a more readily available method to meet the cultural needs for Here we presented a comprehensive discus- every individual client. Therefore, we propose to sion of how cultural factors can be considered integrate interviews that assess ethnic and cul- by behavioral healthcare providers in assess- tural background as a general approach to cultur- ment and treatment of SSOPD. Behavioral ally adapt any kind of evidence-based treatments health specialists are most often in the role of for SSOPD. When possible, cultural adaptations conducting assessments for SSOPD, and that already exist and are supported in the therefore we outlined in detail how cultural research should be utilized. For example, the factors can be considered in all steps of assess- DSM-5 includes the Cultural Formulation ment. First, a diagnostic evaluation may use Interview whose 16 questions address (1) the cul- semi-structured interviews (such as the SCID) tural definition of the problem; (2) cultural per- that have been translated into multiple lan- ceptions of cause, context, and support; and (3) guages and consider culture-related diagnostic cultural factors affecting self-coping and past issues outlined in the DSM-5. Assessment of help seeking behavior. Lately, cultural interviews symptom severity should include culturally for specific ethnic groups are also being devel- sensitive symptom severity measures and gen- oped. For instance, guidelines for Hispanic adult erally be informed by literature on different assessment (National Hispanic and Latino ATTC, symptom expressions across ethnicities and 2017) address assessment of risk/stressors and racial groups. Last, when conducting assess- protective factors in the following eight domains: ments of neurocognition and functional (1) discrimination of stress defined as problems impairments of patients with schizophrenia due to ethnic or cultural orientation; (2) marital spectrum disorders, it is necessary to know for stress which may be related to cultural values; (3) which cultural groups such measures have health stress related to available or accessible been validated and to consider fairness in test- healthcare (including culturally appropriate ing. We concluded the chapter with a review of care); (4) family stress that may be related to how cultural factors have been considered in family conflict, low family unity, or cultural dif- psychosocial treatments of schizophrenia. ferences; (5) parental stress that may reflect cul- This review showed that the most research on tural differences in parenting or cultural culturally adapted evidence-based therapy orientation between children and parents; (6) approaches is available for cognitive behav- occupational stress that reflects problems related ioral therapy, social skills trainings, and fam- 27 Cultural Considerations and Schizophrenia 395 ily psychoeducation approaches. We propose a Ayllon, T., & Azrin, N. H. (1968). The token economy: A motivational system for therapy and rehabilitation. general approach to integrate a consideration Englewood Cliffs, NJ: Prentice Hall. of cultural factors into any evidence-based Baker, K., Howell, C., & Findling, R. L. (2016). 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Nina B. Paul, Lance A. Lopez, Michelle N. Strong, and Bradley Donohue

Introduction we provide a review of culturally sensitive evidence-based measures specific to screening, diag- Substance use prevalence rates have been found nostic assessment, intervention progress, and to vary across race/ethnicity and other cultural outcome assessment. factors (CDC, 2017), yet there are very few Then, evidence-based behavioral substance reviews that have been focused on the evidence- use treatments are reviewed, available research based management of cultural factors when con- for the cultural groups for which these treatments ducting behavioral treatment in diverse have been adapted are underscored, and a general populations. The overall goal of this chapter is to approach on how treatments can meet cultural provide behavioral health-care providers in the group needs is outlined. The evidence-based substance use field with a comprehensive Semistructured Interview for Consideration of approach to how cultural factors may be consid- Ethnic Culture in Therapy (SSICECTS; Donohue ered, i.e., from initial contact with the client to et al., 2006) is emphasized. Clinicians may find a intervention termination, and consistent with the review of different approaches useful in develop- recently published multicultural guidelines by ing their own culturally sensitive substance use the American Psychological Association (2017). treatment plans. The chapter begins with a review of the most Lastly, there is a focus on how practitioners recent data on prevalence of substance use disor- within integrated behavioral health-care systems ders across age, sex, ethnic/racial groups, and can consider cultural factors from the initial con- oother demographic factors. We also review the tact, across different providers in the treatment underutilization of treatments for substance abuse team, and in joint goals of the treatment team. In across cultural groups and discuss attitudinal and substance use facilities, behavioral health-care structural barriers to treatment engagement. Next, providers often closely work together with other providers such as psychiatrists, nurses, social workers, and administrators, among others. N. B. Paul (*) · M. N. Strong · B. Donohue Therefore, clinicians may find a joint approach Department of Psychology, University of Nevada, on how to consider cultural factors useful. In Las Vegas, Las Vegas, NV, USA e-mail: [email protected]; summary, this chapter will advance the field by [email protected] providing a comprehensive and evidence-based L. A. Lopez model on how to consider cultural factors in sub- Las Vegas, NV, USA stance use treatments.

Prevalence of Substance-Related report that the 12-month prevalence rate of sub- Disorders in the United States stance use in sexual minority individuals compared to sexual majority individuals tended to be In 2017, the Centers for Disease and Control higher for cocaine (5.1% vs. 1.8%), heroin (0.9% Prevention reported high rates of substance use vs. 0.03%), hallucinogens (5.0% vs. 1.6%), among the general population in the following inhalants (3.7% vs. 0.3%), methamphetamine domains: any illicit drug use (10.6%), cannabis (2.3% vs. 0.6%), prescription tranquilizers (5.9% (8.9%), prescription misuse (2.3%), alcohol vs. 2.2%), prescription stimulants (4.2% vs. (50.7%), binge alcohol use (24.2%), heavy alco- 1.9%), and prescription sedatives (1.2% vs. hol use (6.0%), tobacco (23.5%), cigarettes 0.6%) (2016). (19.1%), and cigars (4.6%). Across all domains, Further, the prevalence of substance use disor- males reported more substance use than females ders depends on factors such as religion, disabil- (CDC, 2017). Caucasian Americans had the ity, or military status. The National Center on highest prevalence rates for alcohol use (56.3%), Addiction and Substance Abuse at Columbia binge alcohol use (25.4%), and heavy alcohol use University reported that adults who attended reli- (7.2%); African Americans had the highest prev- gious services at least once weekly were less alence rates for cigar use (7.6%). Native likely to report alcohol use, binge drinking, Americans had the highest prevalence rates for tobacco use, marijuana, and other illicit drugs tobacco of any kind (37.9%) and cigarettes spe- compared to those who never attend religious cifically (31.3%); Latino Americans reported services (2001). Research has also shown a nega- high prevalence rates for alcohol use (42.5%) and tive relationship between religiosity and sub- tobacco use (16.8%); and multiracial individuals stance use (Kelly, Polanin, Jang, & Johnson, had the highest prevalence rates for any illicit 2015). According to the US Census Bureau, drug use (20.2%), cannabis (17.7%), and misuse among individuals with confirmed disabilities of prescription drugs (3.7%) (CDC, 2017). A (one in five individuals), males and females both study on substance use in foreign-born individu- reported higher rates of substance-related disor- als in the United States (African, European, ders compared to non-disabled individuals Asian/Pacific Islander, Mexican, Puerto Rican, (2012). According to the 2012 Behavioral Health other Hispanic/Latino) reports overall lower rates Report, of the male military members in a reserve of alcohol-related substance use compared to component of the armed forces, 17.7% reported US-born individuals, although immigrants from any mental illness, 8.1% reported any substance Europe and Puerto Rico did not share these trends use disorder, 6.4% reported any alcohol use dis- (Szaflarski, Cubbins, & Ying, 2011). The same order, and 1.9% reported any illicit drug use dis- study indicated that gender, marital status, and order. Of those retired from the reserves, females education were not significant predictors for reported higher rates of any mental illness alcohol abuse and dependence, but did find the (24.8%) compared to males (14.3%), and males following: age was a significant predictor for reported higher rates of substance use disorders alcohol abuse and dependence problems among (6.8% vs. 4.1%), alcohol use disorder (6.1% vs. foreign-born Africans and Puerto Ricans; gender 3.8%), and illicit drug use disorders (1.2% vs. was a significant predictor for binge drinking 0.9%) (SAMHSA, 2012). among foreign-born Mexican, Puerto Rican, and other Hispanic/Latinos; and trauma was a significant predictor for substance intoxication in both Underutilization of Substance Use US- and foreign-born individuals with higher Treatments significance among foreign-born Asian/Pacific Islanders and Mexicans (Szaflarski et al., 2011). When designing substance use treatments to Scientists at the Substance Abuse and Mental address cultural factors, one may begin by asking Health Services Administration (SAMHSA) which cultural groups have an unmet need in 28 Cultural Considerations and Substance Use Disorders 405 receiving services. Evidence supports that an Affordable Care Act reduced the uninsured rate unmet need for substance use treatments is high of individuals with substance use disorders by for Asian Americans and Latino Americans, yet 5.1% and payment by Medicaid for substance use African Americans are less likely to have an disorder increased by 7.4%, no significant unmet need for specialty substance use treatment changes have been found in treatment settings for compared to Caucasian Americans (Mulvaney- substance use disorders (Saloner, Bandara, Day, DeAngelo, Chen, Cook, & Alegría, 2012). Bachhuber, & Barry, 2017). The task of reaching Asian Americans and Hawaiian-born Americans minority groups and disseminating necessary ser- are also less likely to see mental health-care pro- vices may ultimately have to be a joint effort viders or physicians for alcohol problems com- tackled by health-care providers, politicians, pared to Caucasian Americans (Goebert & advocates, and society at large. Nishimura, 2011). Regarding help seeking for substance use-related problems, African Americans and Latino Americans are less likely Cultural Factors Relevant to endorse attitudinal barriers for alcohol prob- to Assessment of Substance- lems, yet African Americans are more likely to Related Disorders endorse structural barriers (Verissimo & Grella, 2017). Interestingly, across racial groups includ- Underreporting of substance use has been found ing African Americans, Caucasian Americans, to be equal for women and men, but higher for and Latino Americans, women are more likely youth compared to adults (Stockwell, Zhao, & than men to endorse attitudinal barriers for seek- Macdonald, 2014). There is also some evidence ing help for substance use problems (Verissimo that underreporting is more likely for African & Grella, 2017). Several studies have also con- Americans compared to other groups (Perera- sidered age as a factor that may affect utilization Diltz & Perry, 2011). Clinicians may address of substance use treatments. For example, com- possible reasons for underreporting such as cul- pared to Caucasian American adolescents with a tural mistrust or concerns about confidentiality. substance use diagnosis, African American ado- Discussing links between accurate assessment lescents with substance use diagnosis reported and treatment outcome and establishing a good receiving less specialty and informal treatment, working alliance may also increase the validity of and Latino Americans reported receiving less substance use assessments. informal care (Alegria, Carson, Goncalves, & Keefe, 2011). In addition to age, gender, and race/ethnicity, a recent study also supports that Screening Measures for Substance there is an unmet need for substance use treat- Use ment utilization among sexual minority groups such as lesbian and bisexual women (Jeong, There is much evidence supporting the routine Veldhuis, Aranda, & Hughes, 2016). use of screening measures for substance use in It has been suggested that such disparities in primary care settings (McPherson & Hersch, substance use treatment among cultural minority 2000; Pilowsky & Wu, 2013; Timko, Kong, groups may be addressed through state policies Vittorio, & Cucciare, 2016). The Alcohol Use and increased eligibility for public insurance Disorders Identification Test (AUDIT; Saunders (Alegria et al., 2011). Currently, only 60% of US et al., 1993) is consistently cited as the gold stan- counties have at least one outpatient facility for dard for a screening measure for alcohol use and substance use treatment that accepts Medicaid, has been translated into numerous languages (for and counties with more African American resi- reviews, see Babor & Robaina, 2016; Reinert & dents, uninsured residents, and rural residents are Allen, 2002). Importantly, there is no evidence of less likely to have one of these facilities gender or racial/ethnicity bias in the AUDIT (Cummings, Wen, Ko, & Druss, 2014). While the reported in a study employing receiver operating 406 N. B. Paul et al. characteristic (ROC) curve analysis (Volk, Diagnostic Assessment of Substance- Steinbauer, Cantor, & Holzer III, 1997). Related Disorders Furthermore, regarding adolescents, there is support that the AUDIT performs as well as other The SCID remains the gold standard for in-depth screening measures for adolescent substance use assessments of substance use, with the goal of (Knight, Sherritt, Harris, Gates, & Chang, 2003). arriving at a valid differential diagnosis. The sub- Also, the AUDIT has been validated as a good stance use section assesses for all possible sub- screening measure for alcohol use in older adults stances, addresses specifiers (remission, (Beullens & Aertgeerts, 2004). Given the good controlled environment, and severity), checks for performance across gender, race/ethnicity, and current maintenance therapy and includes a age groups, we recommend the AUDIT as a cul- detailed chronology. The SCID has been trans- turally appropriate screening measure for alcohol lated into 15 languages. Yet, despite the increas- use. Its brief administration time of 10 min or less ing number of Spanish speakers in the United makes it feasible to be introduced to most set- States, only the research version but not the clini- tings. Even the brief AUDIT-C with only three cian version of the SCID has been translated into questions has been found to be a valid screening Spanish. To consider cultural factors that may measure of alcohol use risk (Bradley et al., 2007; impact the SCID interview, clinicians may choose Bush, Kivlahan, McDonell, Fihn, & Bradley, to add the cultural formulation interview outlined 1998; Rubinsky, Dawson, Williams, Kivlahan, & by the American Psychiatric Association (APA) in Bradley, 2013). the Diagnostic and Statistical Manual of Mental The National Institute on Drug Abuse Disorders (fifth ed.; DSM-5; 2013), which con- (NIDA) provides an online list of evidence- sists of 16 questions that address the cultural defi- based screening tools for substance use (2018), nition of the problem (i.e., cultural perceptions of which includes the AUDIT along with the fol- cause, context, and support and cultural factors lowing: Screening to Brief Intervention (S2BI; affecting self-coping and past help seeking). In Levy et al., 2014); Brief Screener for Alcohol, this way, the cultural formulation interview allows Tobacco, and other Drugs (BSTAD; Kelly et al., the clinician and client to define the diagnosis 2014); Tobacco, Alcohol, Prescription medica- from a cultural perspective and plan treatment by tion, and other Substance use (TAPS; McNeely considering cultural factors. et al., 2016); Opioid Risk Tool (Webster & Webster, 2005); CAGE-AID (Brown & Rounds, Diagnostic Criteria of Substance-Related 1995); and the CAGE (Ewing, 1984). NIDA Disorders The SCID results can then be indicates whether these screening measures are employed to arrive at a diagnosis in accordance to appropriate for use with adolescents and adults. the DSM-5 (APA, 2013). In the DSM-5, Future studies may focus on evaluating the use substance-related disorders are split into sub- of these measures across genders and racial/ stance use disorders and substance-induced disor- ethnic groups. The Substance Abuse Subtle ders. For substance use disorders, four criteria Screening Inventory (SASSI) is another sub- groupings are outlined in the DSM-5: The first stance use screening measure which demon- grouping describes impaired control over the sub- strated good performance across age, gender, stance and includes larger and longer use than and ethnicity groups (Lazowski & Geary, originally intended; unsuccessful desire or 2019). Finally, clinicians may also opt to attempts to reduce or stop use; significant amount administer the screening module for alcohol of time of obtaining, using, or recovering from and substance use included in the Structured substance use; daily activities revolving around Clinical Interview for the DSM-5 (fifth edition, the substance; and craving. The second criteria clinical version; SCID; First & Williams, 2016), grouping addresses social impairment such as not which notably differentiates between lifetime meeting obligations at work, school, or home; and past-year abuse. having increased interpersonal or social problems 28 Cultural Considerations and Substance Use Disorders 407 due to substance use; or neglecting important (APA, 2013): For example, alcohol intoxication social activities due to substance use. The third may be discouraged or encouraged depending on grouping describes risky behavior by substance one’s culture. Caffeine withdrawal may be more use in hazardous situations or substance use likely for caffeine users who fast for religious rea- despite physical or psychological problems. The sons. Diagnosis of cannabis-related disorders may last grouping addresses pharmacological effects be affected by different acceptability and laws in of tolerance and withdrawal. Substances used for cultural groups. Ketamine use may be more preva- medical use, unless used inappropriately, do not lent in Caucasian Americans, and phencyclidine constitute a diagnosis. The severity of substance use may be more prevalent in African and Latino use disorders can be classified on a continuum (2 Americans. Hallucinogens may be used as part of or 3 symptoms = mild; 4 to 5 = moderate; 6 or religious practices by Native and Latino more = severe). Furthermore, the course of the Americans. Inhalant use may be more prevalent in disorder can be specified as “in early remission,” native and aboriginal communities. Opioid use “in sustained remission,” “on maintenance ther- may be related to higher availability of opioids in apy,” or “in a controlled environment.” Substance- certain communities (e.g., medical personnel). induced disorders are split into substance Sedative, hypnotic, or anxiolytic use disorders intoxication, substance withdrawal, and other may be more prevalent in different countries due substance-/medication-induced mental disorders to prescription patterns and availability. Stimulant in the DSM-5. The essential criteria for substance use can affect “all racial/ethnic, socioeconomic, intoxication are the recent ingestion of a sub- age, and gender groups” (APA, 2013, p. 565), but stance and subsequent related clinically signifi- admittance patterns for primary methamphet- cant behavioral and psychological changes. The amine-/amphetamine-related disorders vary across essential criteria for substance withdrawal are racial/ethnic groups. Tobacco use acceptance may withdrawal symptoms due to the reduction or ces- vary across racial/ethnic groups. Also, some cul- sation of prolonged substance use. tures may use indigenous substances that are still widely unknown. Ten classes of substances are addressed in the DSM-5: alcohol; caffeine; cannabis; hallucinogens; inhalants, opioids; sedatives, hypnotics, Progress and Outcome Assessment and anxiolytics; stimulants; tobacco; and other of Substance Use Treatment or unknown substances (APA, 2013). Further diagnoses can be made for individual substances Many substance use treatment programs monitor as they relate to that substance. For example, alcohol and drug use with biological testing such alcohol-related disorders include alcohol use as urine analysis or hair sample analysis (Allen, disorder, alcohol intoxication, alcohol with- Donohue, Sutton, Haderlie, & LaPota, 2009). drawal, other alcohol-induced disorders (e.g., However, these methods inherently only permit alcohol-induced psychotic disorder; alcohol- assessment of relatively recent alcohol and drug induced depressive disorder, etc.), and unspeci- use. Therefore, we recommend complementing fied alcohol-related disorders. Notably, criteria biological measurements of substance use with for substance-induced disorders are not applied behavioral assessments which allow assessment to all classes of substances. For example, there is of past substance use. Another benefit of behav- no diagnosis of intoxication due to tobacco and ioral measures of substance use is that they may no diagnosis of substance withdrawal due to gather valuable information about events and phencyclidine or other hallucinogens. triggers that contributed to substance use. Including behavioral progress and outcome mea- Culture-Related Diagnostic Issues Authors of sures can also help in gathering data about the the DSM-5 point out culture-related diagnostic treatment’s efficacy (Duncan, 2014) which ulti- issues for some substance-induced disorders mately can justify financing of the treatment. 408 N. B. Paul et al.

The timeline followback procedure (TLFB; for substance use treatments that assess interven- Sobell & Sobell, 1992; Sobell, Sobell, Klajner, tion helpfulness and client compliance. First, the Pavan, & Basian, 1986) is considered one of the client rates how helpful that session’s interven- gold standards of behavioral measures used to tion was on a seven-point scale. Importantly, the assess past and recent substance use. Originally, clinician emphasizes that the client should not it was developed to assess only alcohol use, but feel obligated to provide high scores and elabo- there is evidence supporting that the TLFB pro- rates that these scores will be used to better cedure can be expanded to include assessment for address the client’s needs. Working from a col- other substances including cocaine, cannabis, laborative approach, the clinician and client will and cigarette use (Robinson, Sobell, Sobell, & employ these ratings to tailor and adjust the treat- Leo, 2014). Interestingly, the use of alcohol and ment plan to the client’s needs. This process also other substances have been found to correlate provides an opportunity to adjust the treatment when assessed through the TLFB procedure plan to any cultural factors that may arise. Next, (Donohue et al., 2004). A clinical trial by the the clinician rates the client’s compliance with World Health Organization found that the TLFB the intervention on a seven-point scale. Factors is a reliable and valid cross-cultural measure and that contribute to this rating include attendance, can be used with English- and Spanish-speaking participation and conduct in session, and home- clients (Sobell et al., 2001). The TLFB procedure work completion. This rating is discussed to involves the clinician and client filling in sub- maintain or improve the client’s benefit drawn stance use into a month-by-month calendar up to from the substance use treatment in the future. 1 year prior to the interview (Sobell et al., 1986; Sobell & Sobell, 1992). First, “anchor events” are recorded such as birthdays, holidays, vacations, Cultural Factors Relevant anniversaries, days at work or in school, days to Therapy for Substance-Related incarcerated, days hospitalized, unprotected sex, Disorders etc. They may also include religious or cultural events. These anchor events help the client Culturally Adapted Treatments remember with more accuracy when substances for Specific Cultural Groups were used. Next, the type and frequency of substances used on each day is recorded. The nature The largest meta-analysis to date on psychoso- of the TLFB procedure makes it easily adaptable cial interventions for substance use disorders to virtually any culture that uses monthly calen- included cognitive behavior therapy, contin- dars. In treatment this procedure may also help to gency management, relapse prevention, and inte- identify triggers and consequences related to sub- grated approaches for cannabis, opiate, cocaine, stance use. We recommend establishing a base- and polysubstance users; moderate effect sizes line of past substance use early in the treatment were reported—with the most efficacy for can- and continuing to use the TLFB throughout treat- nabis and the strongest effect for contingency ment to monitor progress and outcomes. management (Dutra et al., 2008). There is some meta-analytic evidence that contingency management is efficacious for non-prescribed drug Assessment of Intervention use during treatment for opiate addiction (for Helpfulness and Client Compliance meta-analysis, see Ainscough, McNeill, Strang, Calder, & Brose, 2017) and that adding prize- A growing body of literature suggests inquiring based contingency management to behavioral about how helpful the client perceived the session treatment as usual for substance use is related to goals, interventions, and therapeutic relationship short-term abstinence but that this effect is no at the end of each session (Duncan, 2014). longer detectable at a 6-month follow-up Donohue and Allen (2011) designed checklists (Benishek et al., 2014). Another meta-analysis 28 Cultural Considerations and Substance Use Disorders 409 reports that while extrinsically focused contin- ventions (for various psychological disorders not gency management shows medium short-term just substance use disorders) has found a medium follow-up effects, intrinsically focused motiva- effect size for culturally adapted interventions tional interviewing shows small yet longer-last- compared to the original version of the same ing effects (Sayegh, Huey, Zara, & Jhaveri, intervention (Hall, Ibaraki, Huang, Marti, & 2017). Often different therapy approaches for Stice, 2016). Yet, more progress is still needed substance use treatments are combined and regarding cultural adaptations of psychosocial address comorbid disorders. For example, com- treatments focused on substance use disorders. bining CBT with motivational interviewing That there is a need for cultural adaptations is showed small but significant effects for treat- supported by a meta-analysis which indicated ment of alcohol use disorders with comorbid that pre-post-test effect sizes of cognitive behav- depression (Riper et al., 2014). In general, treat- ioral therapy for substance use were significantly ing common comorbid disorders such as anxiety greater for non-Hispanic White clients compared or depression is related to better alcohol use out- to Black and/or Latino clients (Windsor, Jemal, comes (see meta-analysis by Hobbs, Kushner, & Alessi, 2015). A recent review on cultural Lee, Reardon, and Maurer (2011). As the field adaptations of substance use treatments for advances, treatments become more specialized. Latino men suggested that there are still a scarce For instance, a family therapy treatment designed number of publications concerning this topic, and for student athletes with substance use problems overall efficacy results remain contradictory has been shown to be efficacious in a recent ran- (Valdez et al., 2018). There is more research on domized control trial (Donohue et al., 2018). In cultural adaptations of behavioral treatments for addition, other new and growing client popula- substance use disorders in adolescents. A recent tions such as cannabis users have begun to seek meta-analysis indicated that culturally sensitive treatment in greater numbers. This need is being substance use treatments for racial/ethnic minor- met with research that provides evidence that ity youth had greater reductions of post-treatment contingency management, motivational inter- substance use levels compared to other condi- viewing, relapse prevention, and combinations tions, but the authors caution that results were of these approaches with cognitive behavioral restricted by a small number of studies (Steinka- therapy are efficacious for cannabis use disorder Fry, Tanner-Smith, Dakof, & Henderson, 2017). (see meta-analysis by Davis et al. (2015). The A recent meta-analysis of substance use treat- latest research advances also include the utiliza- ments culturally adapted for Latino adolescents tion of information technology, and there is reported small post-treatment and slightly larger meta-analytic evidence that supports Internet- follow-up results, yet also cautioned of heteroge- and computer-based interventions as being effi- neity and performance/selection bias of studies cacious for at least short-term cannabis reduction (Hernandez Robles, Maynard, Salas-Wright, & (Tait, Spijkerman, & Riper, 2013). Todic, 2018). Cultural adaptation of these behavioral treat- The specific nature of cultural adaptations var- ments for substance use disorders is another chal- ies among studies and ranges from simply trans- lenge for our field that has been met to only some lating manuals to considering other cultural degree. A wake-up call came from early reports, factors and frameworks in the construction of the such as a study that found that only 6% of instruments themselves. For instance, the manual reviewed adolescent substance use studies ana- Accommodated Cognitive-Behavioral Treatment lyzed treatment response or moderating factors (A-CBT; Burrow-Sánchez, 2013) for use with related to ethnicity with enough ethnic minority Latino adolescent clients revised content to clients to reach relevance (Strada, Donohue, & include Spanish names in examples and culturally Lefforge, 2006). Since then, more studies have relevant role-plays, included a module on ethnic been conducted, and a recent meta-analysis that identity of Latino adolescents and acculturative investigated the efficacy of psychosocial inter- stress, and increased parent involvement to 410 N. B. Paul et al. address the importance of family in Latino culture substance use disorder. We recommend beginning (i.e., familismo). A randomized control trial found treatment by assessing ethnic background and to that both the A-CBT and standard version of CBT revisit it throughout treatment if it is beneficial for resulted in significant decreased of substance use the client to do so. Results of a randomized control and that results were moderated by ethnic identity trial suggest the Semistructured Interview for and familismo (Burrow-Sánchez, Minami, & Consideration of Ethnic Culture in Therapy Hops, 2015). A noteworthy cultural adaptation for (SSICECTS; Donohue et al., 2006) is an effective African American adolescents was achieved for a method of addressing ethnic and cultural back- risk prevention program that integrated examples ground in treatment. The SSICECTS includes a addressing African literature and history; cultur- six-item questionnaire which clients complete. In ally sensitive teaching strategies such as storytell- treatment, the questionnaire outcomes are fol- ing; a focus on African American values such as lowed by a protocol that includes questions self-determination, responsibility, and unity; and designed to explore the extent to which the client’s involvement of parents (Flay, Graumlich, Segawa, ethnic culture may be relevant to intervention Burns, & Holliday, 2004). A randomized control planning. This process fosters a working therapeu- trial supported that such culturally sensitive pro- tic relationship early in treatment, and the evidence grams reduce risk behaviors for inner-city African supports that administration of the SSICECTS is American adolescents (Flay et al., 2004). An associated with clinicians being rated to have interesting integration of cultural practices and greater knowledge of the clients’ culture and more views with psychosocial treatment for American respect for clients’ cultural background (Donohue Indian/Alaskan youth was accomplished by inte- et al., 2006). grating dialectical behavioral therapy (DBT) with The SSICECTS loads on two cultural factors: a milieu schedule (i.e., school, recreational ther- ethnic cultural importance and ethnic cultural apy, health education, and Alcoholic Anonymous problems. Ethnic cultural importance is assessed 12-step groups) as well as the involvement of a by four questions which address whether the cli- medicine man/spiritual counselor from a local ent’s ethnic culture is a big part of everyday life, tribe who related DBT and mindfulness skills to is of great importance to the client, involves many traditional practices and provided talking circles things the client likes and how ethnic culture and smudging ceremonies (Beckstead, Lambert, might be relevant to treatment. Ethnic cultural DuBose, & Linehan, 2015). The large effect size problems are assessed by asking about offensive of this culturally adapted substance use treatment statements others may have expressed regarding for American Indian/Alaska Native adolescents is the client’s ethnic background and whether the very promising. Despite these promising exam- client may have experienced arguments or prob- ples, future research for cultural adaptations of lems with others because of the client’s ethnic substance use treatments for both adolescents and background. The validation study of the adults are still needed. SSICECTS found that ethnic culture was perceived to be more important for African Americans, Asian Americans, and Hispanic General Approach to Address Americans as compared to Caucasian Americans. Treatment Needs Across Cultural Also, Caucasian Americans reported less ethnic Groups cultural problems compared to other ethnic minority groups, and African American, as com- Despite their established utility in the treatment of pared with Caucasians and other ethnic minority substance use disorders, many evidence-based groups, reported the greatest severity of problems therapies for substance use have not been adapted (Donohue et al., 2006). to consider cultural factors. Here we outline a gen- After the SSICECTS questionnaire, the next eral approach on how the needs of cultural groups step entails a detailed protocol that describes how can be integrated in evidence-based treatments for to follow up on the questionnaire scores. If the 28 Cultural Considerations and Substance Use Disorders 411 client agrees with any of four questions on ethnic Its relatively short administration time of cultural importance, the clinician follows up with 10–20 min allows its incorporation in session acknowledgment (e.g., “You indicated that you plans of other evidence-supported treatments. As agreed your ethnic culture is a big part of your described, we recommended to integrate the life.”), validation (e.g., “I think it’s great that your SSICECTS early on in treatment. Yet, we also ethnic culture is a big part of your life.”), elabora- suggest revisiting ethnic background periodically tion (e.g., “How is your ethnic culture a big part throughout treatment if beneficial for the client. of your life?”), and support (i.e., demonstrates agreement). If the client reports disagreement or is unsure or undecided with any of these four Cultural Factors Relevant questions, then the clinician follows up with to Integrated Behavioral Health acknowledgment (e.g., “You indicated that you Care for Substance-Related disagree there are many things that you like about Disorders your ethnic culture.”), elaboration (e.g., “How was it that you came to not like many things There is a recent trend to strive for integrated behav- about your ethnic culture?”), expressing empathy ioral health care that connects services from behav- or understanding after the explanation is pro- ioral health-care specialists with primary care vided (e.g., “Others have also told me it is hard to (Hunter, Goodie, Oordt, & Dobmeyer, 2017). appreciate their ethnic cultural background when Integrated treatment therefore refers to the integra- their parents don’t take them to cultural events.”), tion of primary care, specialized medical care, psy- assessing if the interviewee was content that dis- chopharmacological care, psychotherapeutic and agreement was reported, and support (e.g., “I behavioral health care, social work services, admin- think that experience would make any child feel istrative services, as well as family support and isolated from their ethnic background.”). input from the client (Peek, 2013). Many facilities If the client agrees with either of the two ques- offering substance use treatment now have a basic tions on cultural ethnic problems, then the clini- treatment model that integrates these services from cian follows up with acknowledgment (e.g., “You the beginning of a client’s admission and continues indicated that others have made offensive com- this approach across multiple levels of care. For ments about your ethnic culture.”), normalizing example, the US Department of Veterans Affairs (e.g., “I can reassure you that others have also has historically been on the forefront of integrated experienced similar comments.”), elaboration health-care approaches for substance use treatment (e.g., “Please, tell me more about how the remarks (VA, 2015). Newer and even more specialized were offensive”; “How have these remarks approaches aim to optimize integrated health care affected you?”), and either praising statements for substance-related disorders. Here, we present an that suggest the individual has grown stronger example of an integrated model of care that is cur- because of the offensive remarks or providing rently utilized at several treatment centers in the empathy for statements that suggest the individ- United States. Any mental health clinician working ual was negatively affected by the offensive in substance use may find it valuable to be informed remarks. If the client disagrees with either of about the role of behavioral health in a treatment these questions, the clinician follows up with team and how an integrated substance use treatment acknowledgment (e.g., “You indicated that you team may consider cultural factors. have not been offended by others due to your ethnic culture.”), elaboration (e.g., “Is this because others have not made remarks about your ethnic Treatment Team culture or you do not get offended by what others say?”), and either praising the client for not being The specific structure and hierarchy of the treat- offended by others or being fortunate not having ment team is institution specific. Some treatment been exposed to offensive remarks. programs place the medical clinician as the team 412 N. B. Paul et al. leader in a “Medical Model,” while some will manages withdrawal (acute and post-acute with- have a psychological clinician function as team drawal syndromes) and the facilitation of medica- leader in a “Clinical Model.” In either case, the tion-assisted treatment (MAT; Roman, Abraham, team leader serves to maintain a unified case for- & Knudsen, 2011) following discharge. MAT can mulation and treatment strategy for the individual involve medications to help prevent relapse (nal- client and to mitigate, manage, and delegate any trexone, acamprosate, disulfiram, etc.) or the man- problems that may arise during care to the appro- agement of a client on maintenance medication in priate member of the treatment team. case of opioid use disorder (buprenorphine or methadone). Medical clinicians can utilize various

Behavioral Health Specialists The role of the resources to assist in considering cultural factors in behavioral health specialist on a substance use their practice. For example, the Clinical Manual of treatment team may be filled by a licensed psy- Cultural Psychiatry addresses psychiatric assess- chologist (who holds a Ph.D.), a licensed profes- ment and treatment of culturally diverse individu- sional counselor (LPC; who holds a Masters), or a als, applies the DSM-5’s cultural approach from a licensed mental health counselor (LMHC; who psychiatrist’s perspective, and discusses ethnopsy- holds a Masters), among others. Given psycholo- chopharmacology (Lim, 2015). Importantly, ethnic gists’ strong training in research, they are well differences in response to psychopharmacology positioned to provide the treatment team with the may only be partially explained by genetics and most up-to-date research on cultural factors influ- may depend on other factors such as cultural encing substance use assessment and therapy as beliefs, attitudes, and behaviors, though future outlined in this chapter. If a psychologist is on the research is needed (Chaudhry, Neelam, Duddu, & treatment team, he/she may conduct psychodiag- Husain, 2008). Given the variation in psychophar- nostic or neurocognitive evaluations and offer macological treatment outcomes that may be individual and group therapy. At many substance dependent on cultural factors, prescribing clini- use facilities, the role of behavioral health special- cians must be culturally competent in order to ists is filled by LPCs and LMHCs. LPCs and ensure the safest and most effective treatment strat- LMHCs may also provide the treatment team with egies for the greatest number of people (Sobralske, valuable information about what cultural factors Kaplan, & Brown, 2012). should be considered when administering behavioral substance use measurements and conducting Administrative and Supportive Treatment counseling services. This chapter can be a valu- Team Members Other members on the team able resource for any behavioral health-care spe- may include social workers, behavioral manage- cialists as they consider the cultural factors ment facilitators, case managers, and insurance important to behavioral substance use treatments, representatives, among others. Representatives and it is the role of the behavioral health specialist from the financial and business office handle to assure that this kind of knowledge is considered insurance and treatment funding issues. They are by the treatment team as a whole. accompanied by specifically trained case managers, who can facilitate the management of other

Medical Clinicians The role of the lead medical psychosocial issues pertinent to the case such as clinician can be assumed by a physician (who holds legal issues, post-treatment housing issues, and a MD or DO) or a nurse practitioner (who holds a completion of employment or disability-related Masters or Doctoral level degree). The medical cli- paperwork (medical leave, disability insurance, nician is responsible for coordinating all aspects of etc.). Rounding out the team are several client the client’s medical care, which includes both the management staff, often called behavioral man- pharmacological treatment of substance use disor- agement technicians, who are specially trained der and diagnosing and treating underlying comor- laymen who function as facilitators of the day-to- bid medical and psychiatric conditions. Regarding day function of the facility (transport of clients, substance use treatment, the medical clinician identification/management of emergent behav- 28 Cultural Considerations and Substance Use Disorders 413 ioral issues, etc.). It has been proposed that social Treatment Goals of the Treatment work in particular is uniquely able to implement Team cultural competence in substance use treatment by addressing existing inequities, advocating for It is important to describe the general goals of the social justice, and fostering community empow- program during the initial contact with the client erment (Sprague Martinez, Walter, Acevedo, (typically during the initial telephone contact) in López, & Lundgren, 2018). order to increase the likelihood of first-session attendance and treatment enrollment (Donohue et al., 1999). After the intake and initial assess- Settings ments, the behavioral health specialist may present assessment results such as the SSICECTS The actualization of an integrated care model outcomes to the treatment team to incorporate begins in the structure of the care provided and cultural factors into the case formulation. The of the physical layout of the facility offering it. overarching purpose of the treatment team is to Treatment must center around the problem in create a multidisciplinary and culturally sensitive question at its presenting level of severity. The case formulation for every client in order to facil- American Society of Addiction Medicine itate a synergistic approach to formulating indi- (ASAM) delineates the following levels of care vidual treatment goals. placement for adults: medically managed inten- Long-term treatment goals may include sive inpatient services (level 4), medically moni- accepting the diagnosis of a substance-related tored intensive inpatient services (level 3.7), disorder, committing to a substance use treat- clinically managed high-intensity residential ment program, increasing knowledge about sub- services (level 3.5), clinically managed stance use and the recovery process, adhering to population-specific high-intensity residential sobriety, withdrawing from substances and sta- services (level 3.3), clinically managed low- bilizing physically and emotionally, applying intensity residential services (level 3.1), partial behavioral coping strategies, and establishing a hospitalization services (level 2.5), intensive supportive recovery plan (Jongsma, Peterson, & outpatient services (level 2.1), outpatient ser- Bruce, 2014). There are many opportunities to vices (level 1), opioid treatment programs incorporate cultural considerations into these (OPT—level 1), and early intervention (level goals and for the treatment team to collaborate 0.5) (Mee-Lee, Schulman, Fishman, Gastfriend, on achieving these goals. For example, a com- & Miller, 2013). These levels differ for adoles- mon issue may be that the cultural beliefs of a cent populations, and ASAM criteria have been client negatively affect medication adherence. In culturally adapted for special populations includ- such cases, the client, medical clinician, and ing older adults, parents or prospective parents, behavioral health specialist may collaborate and persons in safety-sensitive occupations, and per- introduce routine meetings in which the client’s sons in criminal justice settings (Mee-Lee et al., cultural concerns are addressed, psychoeduca- 2013). Each level of care as described here pro- tion is provided, psychopharmacological treat- vides its own challenges and opportunities for ment is adjusted according to cultural beliefs, implementation of a culturally sensitive approach and behavioral techniques such as medication to treatment—beginning with a specific cultural monitoring logs are utilized. When updating group’s view of medication usage and hospital- treatment plans, prior assessment outcomes ization in levels 4 through 3 and progressing to related to cultural factors should be revisited to proper selection of groups and individual thera- note progress. At the end of treatment, termina- pist in the outpatient settings. Culturally sensi- tion sessions should include a reflection on how tive treatment choices as described in this chapter cultural factors have been incorporated into the must be made to ensure the best possible out- treatment as this may affect sustained recovery comes at each level. after treatment completion. 414 N. B. Paul et al.

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Behavioral problems in children can include a as poor emotion regulation or distress toler- variety of externalizing and disruptive behav- ance (Martel, 2009) and difficulties with iors, characterized by difficulties with self- impulse control (Lansford et al., 2017). Factors control of both behaviors and emotions such as family financial difficulties and paren- (American Psychiatric Association [APA], tal rejection also increase the risk of children 2013). Disruptive behaviors include, but are displaying externalizing behaviors (Lansford not limited to, noncompliance and defiance et al., 2017). Research has consistently demon- with adults, verbal and physical aggression, strated that parenting practices that are harsh, argumentativeness, bullying and intimidation, inconsistent, neglectful, or traumatic contrib- destruction of property, theft, fire setting, and ute to behavioral problems in children (e.g., cruelty to people or animals (APA, 2013). APA, 2013; Duncombe, Havighurst, Holland, Disruptive behaviors, and their associated & Frankling, 2012). Consequently, the child’s diagnoses, are common in young children behavioral problems increase the likelihood of (Campbell, Shaw, & Gilliom, 2000), and they more punitive parenting, thus creating a bidi- have historically been the leading cause of rectional relationship between the child’s prob- mental health referrals for children (Harvey, lematic behaviors and the parent’s harsh Metcalfe, Herbert, & Fanton, 2011; Kazdin, discipline. Although parenting practices are 2003; Merikangas et al., 2011). inherently tied to behavioral problems in chil- The development of behavioral problems in dren, it should be noted that cultural factors children has been linked to other concerns such may influence a parent’s beliefs about the etiology of their child’s behavior. For example, in Latinx parents of children with ADHD, the cultural values of familismo and traditional gender roles (e.g., machismo and marianismo) have been correlated with parents’ endorsement of sociological or spiritual etiology of their child’s symptoms (Lawton, Gerdes, Haack, & Schneider, 2014). Thus, discussion of parents’ N. Bennett (*) Department of Psychology, University of Nevada, cultural values and beliefs regarding the cause Reno, Reno, NV, USA of their child’s behavior and symptomology is A. P. Blankenship an important area to assess and integrate into UC Davis Children’s Hospital, Sacramento, CA, USA treatment.

© Springer Nature Switzerland AG 2020 419 L. T. Benuto et al. (eds.), Handbook of Cultural Factors in Behavioral Health, https://doi.org/10.1007/978-3-030-32229-8_29 420 N. Bennett and A. P. Blankenship

Factors Leading to Behavioral perceived to be unsafe (Roche, Ensminger, & Problems in Children Cherlin, 2007). With regard to immigrant groups, Varela Parenting Style et al. (2004) found that Mexican-descent families (including Mexican-American and Mexican The four styles of parenting include authoritar- immigrant) used more authoritarian strategies ian, authoritative, permissive, and neglectful than Mexican and non-Latinx White parents, (Baumrind, 1966; Maccoby & Martin, 1983). indicating that discrepancies in parenting style Authoritarian parents have expectations of com- may be based less on Mexican culture, but pliance and obedience from their children, and rather other factors related to the ethnic minor- they do not leave room for discussion or explana- ity status of Mexican-descent families in the tion of rules. Authoritative parents similarly hold USA. Immigrant groups from Asian nations high expectations for their children, but they are tend to adopt parenting practices of their host more likely to be responsive to their child’s needs culture as they acculturate (Huang et al., 2017). or questions. Permissive parents tend to be Clinicians should attend to the cultural context actively involved in their child’s development of the family in order to understand the parent- and responsive to needs, but they do not set rules ing practices being utilized and should also or hold expectations of their child. Neglectful assess the parents’ reasoning for using certain parents have a tendency to not be involved in practices from a multicultural framework from their child’s life and are generally dismissive of a nonjudgmental position. their child’s needs (Mercado & Atkinson, 2014). Authoritative parenting has generally been regarded as ideal for producing favorable out- Discipline Strategies comes in children and adolescents, including fewer problematic behaviors as well as increased In addition to parenting style, the propensity to self-esteem, developmental competence, achieve- use specific discipline strategies can vary by cul- ment, and mental health functioning (Pittman & ture. Regarding the use of corporal punishment, a Chase-Lansdale, 2001). 2002 meta-analysis by Gershoff found that cor- Parenting style and its relationship to child poral punishment increases as family socioeco- outcomes are influenced by cultural factors, and nomic status (SES) decreases. Religious beliefs thus discrepancies in outcomes remain. For also influence parenting, as families with conser- example, one study of Spanish adolescents found vative Protestant beliefs have been found to be permissive parenting to be associated with the more likely to use physical punishment than fam- most optimal outcomes (Garcia & Gracia, 2009). ilies from other religious backgrounds (Gershoff, Additionally, while authoritarian parenting is Miller, & Holden, 1999) and that religious beliefs generally considered to have deleterious out- shape parents’ acceptance of such punishment as comes for children, parental harshness has actu- a parenting strategy (Ellison & Bradshaw, 2009). ally been associated with positive outcomes in Furthermore, Taylor, Moeller, Hamvas, and Rice Chinese families (Huang, Cheah, Lamb, & Zhou, (2013) found that African-American parents with 2017). Indeed, the positive benefits of parental Christian beliefs were just as likely to use parent- support of the child’s autonomy are stronger for ing strategies advised by religious leaders as they children in the USA when compared to families were pediatricians and that seeking parenting in China (Wang, Pomerantz, & Chen, 2007). advice from religious leaders increased the likeli- Similarly, in low-income urban African-hood that parents would use corporal punish- American families, punitive parenting has been ment, regardless of race or ethnicity. found to be linked to positive child outcomes Taken collectively, the use of physical disci- when the family lives in a neighborhood that is pline techniques by race/ethnicity is unclear. 29 Behavioral Problems in Children 421

Some studies cite that African-American and be noted that, for African-American families, the Latinx parents use corporal punishment most fre- literature is mixed with regard to child outcomes quently (e.g., Berlin et al., 2009; Deater-Deckard, when corporal punishment is used. There is some Dodge, Bates, & Pettit, 1996; Gershoff, Lansford, research to support that the use of severe corporal Sexton, Davis-Kean, & Sameroff, 2012), and oth- punishment is less predictive of externalizing ers cite that non-Latinx White parents use the behaviors than for other racial groups (Lapré & practice more (e.g., Straus, 1994). Chinese immi- Marsee, 2016). Longitudinal studies, however, grant mothers tend to have more favorable atti- have shown that the relationship between corpo- tudes toward spanking than Caucasian mothers ral punishment and negative outcomes does not (Mah & Johnston, 2012). For Latinx mothers in differ by race/ethnicity (e.g., Berlin et al., 2009; the USA, higher levels of acculturation are linked Gershoff et al., 2012) and that positive factors to less use of corporal punishment (Gabriela such as parent warmth do not moderate this asso- Barajas-Gonzalez et al., 2018). It should be noted ciation (Lee et al., 2013). that racial differences in physical punishment have been found to be accounted for by SES (Dodge et al., 1994), suggesting that SES is the Cultural Stress most salient cultural factor in predicting such use of discipline techniques in American families. Culturally relevant stressors may increase the Corporal punishment, in particular, is associ- likelihood of a child displaying externalizing ated with a variety of negative long-term out- behavioral problems. Cultural stress includes comes, including increased externalizing behaviors specific factors such as discrimination, accultura- (e.g., Berlin et al., 2009; Gershoff, 2002; Lee, tive stress, and negative perceived context of Altschul, & Gershoff, 2013). Although the rate of reception (Cano et al., 2015; Lorenzo et al., corporal punishment is on the decline, it is esti- 2017). Utilizing the same definitions as these mated that 85% of children experience physical authors, the parent or child may experience dis- punishment before entering high school (Gershoff, crimination in the form of negative attitudes, 2008). Parental discipline is used to achieve both beliefs, or differential treatment due to member- short-term compliance and long-term behavioral ship in a minority group (Williams & Mohammed, changes; however, corporal punishment is less 2009). Bicultural or acculturative stress refers to effective in achieving short-term compliance than the pressures that a parent or child experiences as other behavioral strategies such as time-out a concurrent member of both the heritage and (Gershoff, 2002; Gershoff & Grogan-Kaylor, host cultures (Romero & Roberts, 2003), such as 2016). Moreover, physical punishment is not learning a new language while maintaining native effective in making long-term behavioral changes language or navigating diverging cultural values because it does not teach appropriate replacement and practices (Torres, Driscoll, & Voell, 2012). behaviors and because it elicits an emotional Finally, the family may perceive that the host cul- response from the child (i.e., fear, anger, sadness; ture is unwelcoming or difficult to achieve suc- Dobbs, Smith, & Taylor, 2006), which interferes cess in, known as the negative perceived context with their ability to understand the underlying of reception (Schwartz et al., 2014). message (Grusec & Goodnow, 1994). Both the child’s and the parent’s experience of Based on parent report, aggression in children cultural stress may impact the likelihood of the is one of the externalizing behaviors that is most child displaying behavior problems. Acculturative likely to result in corporal punishment (Holden, stress has been linked with detrimental parenting Coleman, & Schmidt, 1995). Paradoxically, cor- behaviors and family conflict in Latinx immi- poral punishment in early childhood increases grant families (Williams, Ayón, Marsiglia, child aggression, which in turn elicits more cor- Kiehne, & Ayers, 2017). Externalizing behaviors poral punishment across all races and ethnicities are displayed at higher rates in young Latinx chil- (Gershoff, 2002; Gershoff et al., 2012). It should dren when their parents experience high cultural 422 N. Bennett and A. P. Blankenship stress and financial hardship (Mendoza,basic rights of others (e.g., aggression to people Dmitrieva, Perreira, Hurwich-Reiss, & Watamura, and animals) and/or societal rules and norms (e.g., 2017). In older children, Latinx parents’ endorse- running away, truancy, theft; APA, 2013). CD can ment of high cultural stress (coupled with depres- develop as young as the preschool years but most sive symptoms) was found to predict the commonly develops between middle childhood adolescent’s level of substance use (Lorenzo and middle adolescence, and a diagnosis of ODD et al., 2017). Adolescents’ own experience of cul- is a common precursor to CD. CD is estimated to tural stress has also been linked to higher rates of occur in about 4% of the population, and cultural externalizing behaviors, including substance use, discrepancies have not been noted. Pyromania aggression, and rule-breaking behavior, among (i.e., deliberate fire setting) and kleptomania (i.e., Latinx immigrant youth (Cano et al., 2015). stealing items that are not needed) can also be diagnosed in childhood, but are rare due to the fact that children who display these behaviors often Prevalence and Diagnosis meet criteria for CD. of Behavioral Problems in Children IED is a diagnosis which encapsulates failure to control aggressive impulses, leading to The Diagnostic and Statistical Manual of Mental repeated behavioral outbursts (APA, 2013). As Disorders, Fifth Edition (DSM-5; APA, 2013) written in the DSM-5, IED is characterized by includes disruptive, impulse control, and conduct angry or impulsive outbursts that are dispropor- disorders to account for various presentations of tionate to the triggering event and can be diag- externalizing behaviors. The diagnoses that are nosed in children as young as 6 years. According most common during childhood and adolescence to criteria, IED is diagnosed when low-intensity include oppositional defiant disorder (ODD), outbursts (i.e., tantrums, arguments, physical conduct disorder (CD), and intermittent explo- aggression without injury, or property destruc- sive disorder (IED). Overall, disruptive behavior tion) occur at least twice per week for 3 months disorders are more common in males than in or when three high-intensity outbursts (i.e., phys- females. Additionally, attention-deficit/hyperac- ical aggression that results in injury to people or tivity disorder (ADHD), which is classified as a animals or destruction of property) occur within neurodevelopmental disorder in the DSM-5, and 1 year. Its prevalence is estimated to be around various trauma- and stressor-related disorders 3%, although lower rates have been noted in (e.g., posttraumatic stress disorder (PTSD), areas around the world including Asia, the Middle adjustment disorder) are also commonly present East, Romania, and Nigeria. When childhood with externalizing behaviors during childhood. externalizing behaviors impair functioning, but As discussed in the DSM-5 (APA, 2013), the do not meet criteria for one of the aforementioned diagnosis of ODD is characterized by angry/irri- diagnoses, other specified and unspecified dis- table mood, argumentative/defiant behavior, and ruptive, impulse control, and conduct disorder vindictiveness, which are often exhibited by prob- can be diagnosed (APA, 2013). lematic interactions in interpersonal relationships. Additionally, ADHD is a diagnosis that includes The prevalence rate of ODD is estimated to be hyperactivity and difficulty with impulse control, around 3%, and the cultural differences in this rate which can present with noncompliance, defiance, have not been noted by the APA. Symptoms are and externalized behaviors that are a result of most likely to present between preschool years impulsivity (e.g., theft, aggression, general rule and adolescence; however, without intervention, breaking; APA, 2013). ADHD is estimated to occur they can progress into a diagnosis of CD as well as in 5% of children; in the USA, it is often underdi- a variety of mood-related difficulties. CD is char- agnosed in African-American and Latinx youth acterized by a pattern of behaviors that violate the (Morgan, Hillemeier, Farkas, & Maczuga, 2014). 29 Behavioral Problems in Children 423

To diagnose a disruptive behavior disorder or Assessment of Behavioral Problems ADHD, the child’s symptoms must not be better in Children accounted for by a trauma- and stressor-related disorder such as PTSD or adjustment disorder (APA, Standardized Assessment Systems 2013). Ruling out trauma-related symptoms is imperative because several symptoms of trauma Several standardized measures exist to screen exposure can either mimic or result in externalizing for externalizing behavioral problems in chil- behaviors in children. For example, some of the dren. The Achenbach System of Empirically key criteria of PTSD (i.e., intrusion symptoms, Based Assessment (ASEBA; Achenbach, 2009) avoidance, alterations in arousal and reactivity, and is arguably the most well-known and culturally dissociation) can result in the appearance of an validated assessment system, and it is available externalizing behavioral problem. Avoidance of in over 100 languages. It includes various self- trauma-related thoughts, feelings, and external report forms for the child, parent, and teacher reminders can present as noncompliance as chil- to complete, semi-structured clinical inter- dren may not follow directives in an effort to avoid views, and behavior observation systems. The trauma-related stimuli. Intrusive symptoms (e.g., ASEBA has been normed in 21 cultures around upsetting memories, flashbacks) can lead to emo- the world and includes supplementary modules tional and behavioral outbursts following the trau- such that clinicians may use culturally based matic reminder, resulting in tantrums and verbal or norms to score the measures (e.g., Achenbach physical aggression. Irritability, destructive behav- & Rescorla, 2010). ior, hyperactivity, and difficulty concentrating are Although the above assessment systems symptoms related to alterations in arousal and reac- may be used cross-culturally, it is important tivity. Difficulties in concentration, caused by to note that cultural differences are still either alteration in reactivity or the presence of observed in such assessments. In a study of intrusive memories, can cause children to miss the Child Behavior Checklist (CBCL; part of commands or directions, increasing the likelihood the ASEBA system) in 31 societies across the of unintentional noncompliance. Similarly, states globe, results showed that although mean of dissociation can also result in children not hear- scores were generally consistent, parents in ing commands or not fully complying with instruc- some societies (i.e., Puerto Rico, Portugal, tions. Due to the overlap in presentation of Ethiopia, Greece, Lithuania, and Hong Kong) symptoms, it is important to rule out trauma- and reported more behavioral problems, while stressor-related disorders before diagnosing ADHD parents in other societies (i.e., Japan, China, or a disruptive, impulse control, and conduct disor- Sweden, Norway, Germany, and Iceland) der. Rates of childhood trauma are high, as 10.5% reported fewer behavioral problems (Rescorla of Americans adults reported experiencing emo- et al., 2007). Previous research has shown that tional abuse during childhood, 28.3% reported Asian parents may underreport child behav- physical abuse during childhood, 20.7% reported ioral problems on standardized assessments, sexual abuse during childhood, and 12.7% wit- especially when the problems are at a clinical nessed domestic violence in the home (CDC, level (Chung et al., 2013). Furthermore, cul- 2014). In general, non-Latinx White Americans tural differences have been observed when have been found to endorse trauma at rates higher comparing discrepancies between parent and than other racial/ethnic groups, but African- child report of externalizing behaviors. American and Latinx individuals report higher Specifically, Latinx dyads displayed fewer rates of child maltreatment and childhood exposure discrepancies in reports when compared to to domestic violence (Roberts, Gilman, Breslau, African-American and non-Latinx White Breslau, & Koenen, 2011). dyads (Carlston & Ogles, 2009). 424 N. Bennett and A. P. Blankenship

Considering Trauma Exposure Ramirez, 2002), Chinese (Chan, Lam, Chun, & So, 2006), and Italian (Miragoli, Camisasca, & di As previously mentioned, it is imperative to Blasio, 2015) and languages including Arabic (Al assess for exposure to a traumatic event or sig- Abduwani, Sidebotham, Al Saadoon, Al Lawati, nificant stressor as part of a thorough differential & Barlow, 2017) and Dutch (Grietens, De Haene, diagnosis for children with externalized behav- & Uyttebroek, 2007). iors, as symptoms often overlap. Exposure to trauma and stressors can be assessed through clinical interview and direct questioning of past Treatment of Behavioral Problems traumatic experiences or adverse childhood expe- in Children riences (ACEs). There are also various assessment measures that can be used to assess for Without effective treatment, children who exhibit trauma-related symptoms in childhood including externalizing behavioral problems are at risk for the UCLA Child/Adolescent PTSD Reaction various difficulties later in life. A 25-year longi- Index for DSM-5 (Steinberg, Brymer, Decker, & tudinal study of over 1000 children found that Pynoos, 2004), available in English, Spanish, and after controlling for confounding factors, behav- German. Additionally, the Trauma Symptom ioral problems between the ages of 7 and 9 years Checklist for Children aged 8–16 (TSCC; Briere, were associated with adverse psychosocial out- 1996) and the Trauma Symptom Checklist for comes including engaging in illegal activities, Young Children for children aged 3–12 (TSCYC; substance abuse, mental health difficulties, and Briere, 2005) are available in English and sexual risk-taking (Fergusson, John Horwood, & Spanish. Ritter, 2005). Furthermore, childhood behavioral Abusive parenting techniques should also be problems have also been linked to a multitude of assessed in parent-child dyads when externaliz- health risks in adulthood, including premature ing behaviors are present, due to the findings that mortality, long-term disease, obesity, cigarette aggressive and difficult childhood behaviors have smoking, and lower overall well-being (von been found to elicit harsher parenting practices Stumm et al., 2011). (Baumrind, Larzelere, & Cowan, 2002). Corporal Standard treatments for disruptive behaviors punishment is often viewed as a spectrum that in children include parent management training ranges from minimal spanking to abusive physi- through a variety of efficacious models (e.g., cal acts (Gershoff, 2002). The cyclical nature of Parent Management Training—Oregon Model child aggressive behaviors eliciting corporal pun- [PMTO; Patterson, Reid, Jones, & Conger, ishment, which in turn increases child aggres- 1975], Incredible Years [IY; Webster-Stratton & sion, can result in an increase in both frequency Reid, 2003], and Positive Parenting Program and intensity of parent response. Due to this [Triple P; Sanders, 1999]); parent-child thera- cycle, children with externalizing behaviors are pies (e.g., Parent-Child Interaction Therapy at high risk for experiencing child abuse (Urquiza [PCIT; Eyberg, 1988] and PC-CARE [Timmer, & McNeil, 1996). Past child abuse and the poten- Hawk, Forte, Boys, & Urquiza, 2018]); and tial for future child abuse should be addressed in trauma-focused interventions. Therapeutic inter- a direct and nonjudgmental manner. There are vention should be determined based on a thor- standardized assessment measures that can be ough assessment of symptom presentation, helpful in this assessment, including the Child contributing factors, and family dynamics. Abuse Potential Inventory (CAPI; Milner, 1986, Research has shown that in low- and middle- 1990). The CAPI assesses various factors that are income socioeconomic countries, psychosocial known to correspond with abuse potential (i.e., interventions effectively reduce disruptive distress, rigidity, unhappiness, problems with behavior in children with externalizing behav- child and self, problems with family, and prob- ioral problems (Burkey et al., 2018) and improve lems with others). The CAPI has been validated parenting skills and reduce harsh parenting prac- in a variety of cultures such as Chilean (Haz & tices (Knerr, Gardner, & Cluver, 2013). 29 Behavioral Problems in Children 425

Parent Management Training The standard PCIT protocol has demonstrated and Parent-Child Therapies its effectiveness at reducing externalizing behaviors in children cross-culturally. Still, investiga- There are a variety of parent management train- tions of various cultural adaptations have ing models that have been found effective in demonstrated effectiveness, and PCIT has been treating childhood disruptive behaviors. The adapted for various groups, including Latinxs, commonalities to these programs are that they African-Americans, and Native Americans teach appropriate behavior management skills (McNeil & Hembree-Kigin, 2010), and deaf fam- to parents, so that they can be equipped to man- ilies who communicate with American Sign age their children’s disruptive behaviors inde- Language (ASL; Day, Costa, Previ, & Caverly, pendently. Ethnic minority parents have been 2018). For Latinx families in Puerto Rico, the noted to exhibit lower attendance and participa- involvement of additional family members in tion in parent training groups, and active partici- treatment (consistent with familismo) was a cul- pation in such groups is predictive of treatment tural adaptation that demonstrated effectiveness success (Nix, Bierman, & McMahon, 2009). and acceptability (Matos, Torres, Santiago, Attempts to culturally modify parent manage- Jurado, & Rodriguez, 2006). A comparison of ment training have shown promise. Nuestras PCIT with a culturally modified version for Familias, an adaptation for Spanish-speaking Mexican-American families (Guiando a Niños Latinx families, was found to improve parenting Activos [GANA]) showed that both treatments skills and reduce child externalizing behaviors, improved parenting skills and reduced problem- aggression, and substance use (Martinez Jr. & atic behaviors in children at similar rates, and Eddy, 2005). It is recommended that to help there was no difference in attrition rates (McCabe improve parenting skills in Latinx immigrant & Yeh, 2009). The GANA protocol includes cul- families, therapists encourage and support par- tural adaptations, such as marketing the program ents in the use of culturally informed coping from an educational framework rather than a skills to manage acculturative stress (Williams clinical intervention, increasing session time and et al., 2017). orientation to therapy to assist in rapport building and engagement, and translating, simplifying, PCIT PCIT, an evidence-based treatment and adapting treatment handouts to make them developed by Eyberg (1988), provides parent more culturally relevant. training to caregivers whose children (ages In an examination of PCIT with Chinese fami- 2–7) have disruptive behaviors (McNeil & lies, some cultural issues presented in treatment Hembree-Kigin, 2010). PCIT includes thera- with regard to the parents’ acceptability of strate- pist coaching in real time, to teach specialized gies such as praise and ignore, the concern about therapeutic parenting skills, promote positive family members disapproving of the behavior interactions between parent and child, and to management strategies, and the tendency of par- address disruptive behaviors (McNeil & ents to overdirect the child’s play (Leung, Tsang, Hembree-Kigin, 2010). PCIT has proven ben- Heung, & Yiu, 2009). To address such concerns, eficial for children with disruptive behavior the authors suggested that the therapist empa- disorders (e.g., Thomas & Zimmer-Gembeck, thize and validate the parent’s hesitation to use 2007; Ward, Theule, & Cheung, 2016) and the particular skill, discuss its importance in the ADHD (Bussing, Boggs, Donnelly, Jaccard, & context of the child’s development, and make Eyberg, 2012) and children who have experi- observations about the positive effect the skill has enced maltreatment (e.g., Thomas & Zimmer- on the child’s behavior. With regard to praise, the Gembeck, 2012; Timmer, Urquiza, Zebell, & therapist may teach the parent to use more McGrath, 2005; Timmer, Zebell, Culver, & indirect forms of praise (e.g., using facial Urquiza, 2010). expressions). 426 N. Bennett and A. P. Blankenship

PC-CARE PC-CARE, while a relatively new Summary and Recommendations treatment, has shown success in reducing disruptive behavior in children from a variety of Children with externalizing problems can cultural backgrounds (Timmer et al., 2018). exhibit various disruptive behaviors including Given that it is a brief intervention (i.e., six ses- noncompliance, aggression, property destruc- sions) and can be implemented in a wide variety tion, theft, and cruelty to others. While such of settings, it appeared to be well-suited for children may also experience difficulties with families who may have difficulty accessing emotion regulation and impulse control, parent- treatment due to barriers such as financial cost, ing practices often influence children’s exter- transportation, or lack of available time to par- nalizing behaviors. During intake, providers ticipate in treatment. The PC-CARE manual, can ask about and observe the family’s parent- including client handouts, is available in English ing practice while considering cultural factors and Spanish. such as race/ethnicity, immigration status and acculturation, socioeconomic status, and religion. Parents should be encouraged to discuss Trauma-Focused Therapy their reasons for using such practices and how they fit into the family’s cultural context. Trauma-Focused Cognitive-Behavioral Clinicians should also assess for a history of Therapy (TF-CBT; Cohen, Mannarino, & trauma and the level to which parents use cor- Deblinger, 2006) is an evidence-based treat- poral punishment to determine possible con- ment for children and adolescents (ages 3–17) tributors for the child’s problematic behaviors whose disruptive behaviors are related to trau- and develop an appropriate treatment plan. matic events or symptoms of posttraumatic Functional assessment of the contingencies in stress. TF-CBT not only effectively reduces which the problematic behavior arises may be symptoms of posttraumatic stress, which can useful as well. present as disruptive behaviors, but also Treatments for children with externalizing includes parent interventions and parenting behaviors often include parent management skills components (Cohen et al., 2006; Cohen, training. These interventions focus on teaching Mannarino, & Deblinger, 2017). TF-CBT can parents the skills needed to manage their child’s help reduce disruptive behaviors by increasing behavior. Various protocols exist that have been one’s ability to connect their feelings, thoughts, shown to be effective with ethnically diverse and behaviors; teaching relaxation strategies to families, including PCIT and PC-CARE. Trauma- reduce physiological symptoms; teaching focused interventions that include a parent man- problem-solving, inhibitory control, and social agement component may be useful for skills; and reducing symptoms of avoidance, trauma-exposed youth with externalizing arousal and reactivity, and negative cognitions. behaviors. TF-CBT has been widely researched and dis- Some cultural modifications may be helpful to seminated in the USA (Allen & Johnson, 2012). achieve treatment success. Focusing efforts on It has also been adapted to be delivered via tele- parent engagement and participation, especially health with underserved (e.g., ethnic minority, at the onset of treatment, can increase the likeli- low SES, rural) children who have been exposed hood of improving the child’s behavior as well as to trauma (Stewart, Orengo-Aguayo, Cohen, the parent’s behavior management skills. If par- Mannarino, & de Arellano, 2017) and culturally ents are resistant to using certain skills, clinicians adapted for use in Jordanian culture (Damra, may validate the resistance and engage in a dia- Nassar, & Ghabri, 2014). logue with the parents about their hesitation. 29 Behavioral Problems in Children 427

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Kristin M. Lindahl and Sara Wigderson

Relationship Problems and committed relationships focused nearly exclusively on White, heterosexual, non-Hispanic Social relationships affect our overall sense of couples, but over the past couple of decades, well-being, and perhaps no social relationship there has been increased focus on the dynamics affects adult mental and physical health as much and specific needs of couples from different eth- as the marital relationship (Umberson & Montez, nic backgrounds as well as same-sex couples. 2010). Many couples encounter threats to the This chapter provides an overview of the state of quality of their relationship at some point, and if the literature on relationship challenges and these problems are not addressed, a host of nega- issues in a diverse range of couples. Certainly, tive consequences can occur for the couple. It is within any group, there is a range of cultural val- estimated that about one-third of couples experi- ues and intragroup differences represented, many ence distress or discord at some point in the of which have probably not yet been examined or course of their relationship (Whisman, Beach, & identified, so the following group summaries Snyder, 2008). Marital distress is associated with need to be interpreted with this caveat in mind. an increased risk for a variety of mental health issues including anxiety, depressed mood, and substance abuse disorders (Whisman, 2007) as African American Couples well as physical health issues (Kiecolt-Glaser & Newton, 2001). Studies show that marital satis- The benefits of marriage for African American faction tends to decline over the first 10 years of couples are well documented (e.g., Clayton, marriage (Bradbury, Fincham, & Beach, 2000) Glenn, Malone-Colon, & Roberts, 2005). Despite and chronic relationship distress can sufficiently the known salubrious effects of marriage, how- erode the positive qualities of a relationship that ever, the rate of African American couples in couples ultimately divorce. Recent estimates sug- legally committed relationships has declined over gest that nearly half of all marriages terminate the past couple of decades (Brown, Orbuch, & within the first 20 years (Copen, Daniels, Vespa, Bauermeister, 2008), and census data suggest & Mosher, 2012). The early study of marriage that fewer than half (46%) of African American families are marriage based (Bureau of the K. M. Lindahl (*) · S. Wigderson Census, 2011). African American couples also Department of Psychology, University of Miami, tend to spend less time married, and marital dis- Coral Gables, FL, USA solution rates also are higher for African e-mail: [email protected]; American as compared to White couples [email protected]

(Bramlett & Mosher, 2001; Dixon, 2009). Several to high-stress environments than hostility. They factors have been identified for why this might be also found that financial strain also was nega- the case, with economics being one of the pri- tively related to marital quality. mary influences. Raley, Sweeney, and Wondra Barton and Bryant (2016) examined longitu- (2015) argue that ethnic gaps in marriage began dinal associations among financial strain, trajec- to emerge in the 1960s and have grown since, in tories of marital processes, and increases in part due to societal changes that have increased marital instability concerns among a sample of women’s economic contributions to the house- 280 African American newlywed couples, who hold and made marriage optional. In addition, were followed over the first 3 years of marriage. ethnicity and race are associated with economic Financial strain experienced during the early disadvantage and economic instability, which are years of marriage was associated with increased often rooted in social or structural inequalities marital instability concerns for both husbands (Jones, 1997). Understanding how contextual and wives, and it also predicted declines in wives’ factors such as financial strain impact marital perceptions of expressions of warmth from their quality is particularly important for African husbands. Declines in appraisals of warmth were American couples, who tend to report lower lev- more strongly predictive of marital instability els of household income in comparison to other than financial strain per se, suggesting that finan- ethnic or racial groups (DeNavas-Walt, Proctor, cial strain may exert its influence through its & Smith, 2013). impact on marital processes. In addition to Spillover models of relationship functioning impacting positive interaction quality, some stud- discuss how external stress can negatively impact ies have found financial strain to be positively marital quality (Randall & Bodenmann, 2009), associated with African Americans’ marital con- and generally speaking, they tend to emphasize flict and disagreements (Bryant et al., 2008). In a how external stressors impact marital outcomes 5-year longitudinal study of African American indirectly by affecting marital processes and couples, Cutrona, Russell, Burzette, Wesner, and interaction patterns (e.g., Conger & Elder Jr., Bryant (2011) found education level to predict 1994). Links between financial stress and marital relationship stability, in part through its relation- functioning are well documented (Falconier & ship with income and reduced financial strain. As Epstein, 2011) generally, and important research other studies have found, lower financial strain has begun to emerge on how African American was associated with higher relationship quality couples’ economic issues impact their relation- and greater relationship stability. The impact of ships. Overall, studies show links with lower financial strain can extend beyond the couple marital satisfaction, lower marital quality, and relationships, and Lincoln and Chae (2010) found greater hostility and less warmth in couple inter- that the interaction of financial strain and dis- actions for African American couples (Bryant, crimination can hurt married African Americans’ Taylor, Lincoln, Chatters, & Jackson, 2008; psychological well-being. Overall, couples expe- Conger et al., 2002). riencing financial difficulties evaluated their mar- It has been hypothesized that living in low- riage less positively than couples who are income neighborhoods imposes a high level of financially better off, and they also experienced daily stress on those who live there and that this less rewarding interpersonal interactions. can, in turn, negatively affect the quality of daily Dynamics of the work setting, independent of interactions between spouses. In a study of 202 income, also shows links with marital function- African American couples, Cutrona et al. (2003) ing. Sun, McHale, Crouter, and Jones (2017) dis- found that living in an economically disadvan- tinguished between work-to-home conflict and taged neighborhood was related to display of less work-to-home enrichment in a study of 164 warmth in interactions, but not necessarily higher African American dual-earner couples who were levels of hostility. The authors suggested that interviewed annually across 3 years. Pressure at expressions of warmth may be more susceptible work was associated with marital dissatisfaction, 30 Cultural Considerations in the Context of Romantic Relationships 433 much as it is for White couples. Interestingly, tionship instability (men only), though not longer work hours were associated with marital decreased levels of positive relationship func- dissatisfaction for husbands but were associated tioning (satisfaction). The authors suggest that with marital satisfaction for wives. The authors experiences of discrimination can affect emo- speculate that this may have to do with African tional functioning and behavior, including American’s women’s long history of involvement expressions of anger and aggression. in the labor force and as being the breadwinners. Discrimination experiences do not necessarily When both partners felt a sense of autonomy and lead to erosion of marital satisfaction; however, it accomplishment at work, work experiences were may be that a healthy marriage can provide profound to enrich marriages. tection from the negative consequences of being The above studies highlight the need for clini- exposed to a chronic stressor such as discrimina- cians working with African American couples to tion. Guyll, Cutrona, Burzette, and Russell address environmental stressors that might be (2010) found that when African American cou- impinging on the couple in addition to relation- ples were able to create a relationship context ship factors. In other words, help might be needed that provided mutual warmth and support and to not only reduce financial hardship but also good communication, individuals who are pre- help couples cope with financial- and work- disposed to high levels of hostility appear to be related stress, especially in terms of appraisals protected from the health-corrosive consequences spouses make about one another and how the of discrimination. stress impacts them in their behavioral Clinically, research highlights the importance interactions. of therapists addressing issues related to race and Racial discrimination is a chronic source of racial discrimination when working with African stress for African Americans and can be another American couples (Lavner et al., 2018). In par- external stressor that can “spill over” into cou- ticular, evaluating how stressors unique to their ples’ homelife. Racial discrimination includes minority status are related to their relationship institutional discrimination as well as “everyday” functioning is likely to be meaningful (Boyd- discrimination experiences such as being treated Franklin, Kelly, & Durham, 2008). As summa- with less respect or courtesy and name-calling rized in Lavner et al. (2018), therapists can help (Ajrouch, Reisine, Lim, Sohn, & Ismail, 2010). couples examine the influence of race-based These discriminatory experiences constitute a stressors on their relationship and strategize for unique, culturally specific set of stressors with how to deal with them in the future. This could which African American couples must contend. involve helping the partners develop a strong, Exposure to prejudice and discrimination is asso- positive racial identity and enhancing their ability ciated with worse physical as well as mental to count on each other and support each other as health outcomes (Pascoe & Smart Richman, they cope with race-related stressors. Therapists 2009) and can impact one’s worldview and lead also can acknowledge the challenges of living in to expectations of poor treatment by others a racist culture and the hostile attitudes and (Simons, Chen, Stewart, & Brody, 2003). expectations about others that may consequently Perhaps because of all of the above, experi- result. Therapeutic approaches that promote trust encing discrimination has been shown to nega- and caring as well as support, while at the same tively impact relationship quality (Bryant et al., time recognizing the challenges of being able to 2010). In a sample of 344 low-income African trust others given the current social climate, may American couples, a vast majority of whom had be helpful (Guyll et al., 2010). experienced recent discrimination, Lavner, The marital literature has historically taken a Barton, Bryant, and Beach (2018) found discrim- deficit or problem-oriented model regarding rela- ination experiences to be related to negative relationships in general, but perhaps particularly so tionship functioning, including increased with respect to African American couples, but aggression (men and women) and increased rela- more recent studies have also begun to emphasize 434 K. M. Lindahl and S. Wigderson a strength’s perspective. As Clayton et al. (2005) zations actively promote the institution of mar- point out, many African American couples do riage in and of itself and offer social support for enjoy healthy, happy, and long-lasting marriages. promarriage norms and values such as forgive- African Americans generally have positive atti- ness and sexual fidelity (Fincham et al., 2011). In tudes toward marriage (Curran, Utley, & Muraco, addition to obvious direct associations between 2010; Manning, Longmore, & Giordano, 2007), religiosity and marital stability, indirect effects especially as context for raising children, meet- exist as well. In a sample of almost 500 African ing emotional needs, and providing financial American couples, Fincham et al. (2011) found security (Billingsley, 1992). husband religiosity was related to both their own Religiosity and spirituality are often cited as and wives’ satisfaction with their marriage and sources of important strength for African spirituality in both spouses also was related to American couples. African Americans tend to be greater marital satisfaction. Religious involve- more religious than Whites and Latinos by many ment is particularly important for African indicators of religious commitment. For instance, American women. In a 5-year longitudinal study three-quarters of Black Americans say religion is of African American couples, Cutrona et al. very important in their lives, compared with (2011) found women’s religiosity to be related to smaller shares of Whites (49%) and Hispanics a greater likelihood to marry and also to relation- (59%). African Americans also are more likely to ship stability. One of the reasons for the particu- attend services at least once a week and to pray lar relevance of religiosity or a spiritual life for regularly (Hunt & Hunt, 2001). African American couples appears to be the buff- Numerous studies show religiosity and church ering role of the church and spirituality in the attendance to be positively associated with rela- lives of African American couples who are more tionship quality (Mahoney, 2010; Wolfinger & likely than others to have to deal with economic Wilcox, 2008). African Americans who are mar- disadvantage, racism, and oppression (Bean, ried are significantly more likely to attend reli- Perry, & Bedell, 2002; Boyd-Franklin, 2003). gious services (Blackmon, Clayton, Glenn, Although religiosity is positively linked to mar- Malone-Colon, & Roberts, 2005), and several ital quality for couples from a variety of different studies show spiritual experiences to be an impor- ethnic backgrounds, the effect has been shown to tant component for success for many African be stronger for ethnic minority groups (e.g., American couples specifically (e.g., Fincham, African American, Hispanic American, Asian Ajayi, & Beach, 2011). Brody, Stoneman, Flor, American couples) as compared to White couples. and McCrary (1994) found that religiosity was In a survey of over 1000 couples, Perry (2016) related to better-quality marital interaction and found ethnic minority couples reported more lower levels of marital conflict in a sample of expressive forms of love with higher levels of reli- rural African American families. In a more recent giosity as compared to White couples and Black effort to learn more about strengths in enduring and Asian couples also reported a stronger associ- African American relationships, Phillips, ation between religiosity and marital satisfaction Wilmoth, and Marks (2012) recruited 71 church- than White couples. This study also helps explain attending couples, who had been married an aver- the paradoxical set of findings that though African age of 32 years. In this qualitative study, the American couples tend to be more religious than couples reported being happily married and White couples (Taylor, Chatters, & Levin, 2004), among the factors that they credited for their they also tend to experience lower levels of marital marital success included attending church fre- satisfaction (Raley & Sweeney, 2009). Perry quently, praying frequently, and believing that (2016) found that while ethnic minority couples their faith has played a large role in their marital reported lower marital quality than Whites at low longevity. levels of religiosity, marital quality was higher for Religiosity is associated with marital success, the ethnic minority couples than Whites at high no doubt at least in part because religious organi- levels of perceived spousal religiosity. 30 Cultural Considerations in the Context of Romantic Relationships 435

Including a religious or spiritual component to first-generation Mexican immigrant couples, marital interventions has shown to be effective in Helms et al. (2014) found economic pressure and enhancing outcomes for African American cou- cultural adaptation stress to be linked with ples. A randomized clinical trial found that depressive symptoms, which in turn was associ- African American couples showed greater ated with negativity in marital interaction and improvement in marital quality relative to a con- low marital satisfaction. Similarly, Falconier, trol group when they participated in a marital Nussbeck, and Bodenmann (2013) found that the enhancement program that incorporated spiritu- ways in which couples cope can lessen the link ality and prayer (Beach, Hurt, Fincham, McNair, between immigration stress and marital satisfac- & Stanley, 2011). African American women also tion for Hispanic couples, especially for wives. showed greater increase in marital quality to the Although research on Hispanic couples is spirituality- and prayer-focused version of the continuing to grow, relatively few studies have marital program than they did to a culturally sen- focused on issues that may be specifically rele- sitive version of the intervention program that vant to Hispanic couples. However, one of the was designed to be Afrocentric but did not include issues that have been the focus of multiple stud- a spiritual component. ies is acculturation or acculturative stress. It is Several other areas of strength have been iden- important to note that much of this research has tified in African American couples. African been focused on Mexican American couples. Americans tend to be more egalitarian than Acculturation can be operationalized in different European Americans (Broman, 2005; Hunter & ways, but it commonly refers to the degree to Sellars, 1998). Husbands’ participation in house- which an individual endorses beliefs, attitudes, hold responsibilities and childcare can serve as a and behaviors of their culture of origin, the domi- protective factor against divorce in African nant culture in their new environment, or both American couples (Orbuch, Veroff, Hassan, & (Negy & Snyder, 1997). Horrocks, 2002). High involvement with Some studies have found a link between extended family also has been shown to be related acculturation and marital distress for Mexican to marital quality (McAdoo, 1981). Americans (Negy & Snyder, 2000; Vega, Kolody, & Valle, 1988), and Negy, Hammons, Reig- Ferrer, and Carper (2010) found that accultura- Hispanic American Couples tive stress was associated with marital distress among Hispanic immigrant women but that Though limited in scope and quantity, research to social support buffered these negative effects. In date suggests that Hispanic couples experience a literature review of primarily Mexican marital distress at a similar rate to other couples, American (MA) couples, Orengo-Aguayo at least as compared to non-Hispanic White cou- (2015) noted that communication styles of ples (Bulanda & Brown, 2007). Given that Mexican American couples vary as a function of Hispanics comprise the largest ethnic minority acculturation. Specifically, research suggests group in the United States, it is important to that first-generation (less acculturated) Mexican establish a research base on marital quality for American couples tend to prefer to communicate Hispanics. However, little is known about what rather than avoid conflict, whereas more accul- factors might be uniquely important to consider turated couples tend to report more conflict and when working with Hispanic couples. It is possi- verbal aggression during conflicts. Orengo- ble that the combined effects of ethnicity and Aguayo (2015) also discussed how first-genera- economic stress may place some Hispanic cou- tion and less acculturated Mexican American ples at higher risk compared to non-Hispanic couples have a decreased risk of experiencing White couples. A couple of recent studies suggest marital dissolution and dissatisfaction compared that external stressors impact marital satisfaction to second- and third-generation Mexican indirectly for Hispanic couples. In a study of 120 American couples. 436 K. M. Lindahl and S. Wigderson

Acculturation differences between husbands connectedness among family members through and wives have also been linked to lower marital their obligation to protect, honor, respect, and quality in Mexican-origin couples, with the rela- support the family (Falconier et al., 2013). The tionship between acculturation (adoption of couples in the Perez et al. (2013) study indicated American cultural practices) and enculturation being aware of how struggles in their marriage (maintenance or retention of culture of origin) affected their children and extended family mem- implicated in understanding the complex role of bers. Perez and colleagues also discuss how acculturation and how it relates to relationship machismo/marianismo is used to describe gender functioning (Cruz et al., 2014). Cruz and col- differences in Hispanic culture, with machismo leagues found cultural similarities between cou- representing an excessive focus on manliness and ples to generally be associated with positive chauvinism and marianismo representing the dis- marital quality, though interactive effects between play of feminine traits that stem from virgin vir- acculturation and enculturation demonstrate the tues, like being pure and subdued. In this study, importance of assessing cultural orientation in a female focus group participants discussed how multidimensional manner. In addition, genera- women were expected to stay at home and that tion status, which is often considered a marker men generally did not offer to help around the for acculturation, has been linked to marital dis- house. The couples in this study also reported tress for Hispanic couples (e.g., Casas & Ortiz, that it was helpful for the marital program to 1985). Although findings are varied, studies tend address gender-typed differences in the roles that to find greater marital distress for couples with men and women were expected to play in a higher levels of acculturation toward the domi- marriage. nant culture. An assessment of acculturation and Respeto and personalismo are also important enculturation would seem to be a potentially factors to consider when working with couples. important component when conducting a cultur- Respeto is a Hispanic family value that refers to ally sensitive marital intervention. the traditional perception of hierarchal authority Along with acculturation, a few additional in a family, and it has also been found to affect specific factors have been proposed to be included relationship health (Garza & Watts, 2010; in marital intervention programs to make them Gutierrez et al., 2014). Gutierrez et al. (2014) more culturally inclusive of issues important to advise marital educators and therapists to be well Hispanic couples. These factors include versed in this construct so that cultural norms are familismo, machismo/marianismo, respeto, and not unknowingly violated. Personalismo is a personalismo (Gutierrez, Barden, & Tobey, 2014; value that refers to placing higher emphasis on Perez, Brown, Whiting, & Harris, 2013). In a close, personal relationships, rather than imper- qualitative study of Latino men and women who sonal or formal relationships (Añez, Paris Jr., had participated in a marriage and relationship Bedregal, Davidson, & Grilo, 2005). Furthermore, education program, Perez et al. (2013) found that personalismo involves perceiving people who their focus group participants placed value on care for their family as more valued than those attention to issues of familismo and machismo/ who have material wealth (Gutierrez et al., 2014). marianismo. Familismo has been described as a Gutierrez et al. (2014) suggest that due to person- Hispanic/Latino family value in which family alismo, Hispanic/Latino clients may inquire comes before the individual. This includes sacri- about a therapist’s personal life. No research to ficing individual desires if these interfere with the date has yet examined how acculturation issues wants of the family, keeping a strong emotional are related to familismo, machismo/marianismo, and physical bond among family members, and respeto, and personalismo or how interactions providing support of any kind to the family in between these variables affect marital quality, but times of need (Lugo Steidel & Contreras, 2003). these are important directions for future studies This construct emphasizes interdependence and and for therapists to consider. 30 Cultural Considerations in the Context of Romantic Relationships 437

Asian American Couples Along with socioemotional variables that can be addressed in couples therapy, there are addi- Research is also limited when it comes to under- tional factors that therapists may want to consider standing the factors that impact relationship for Asian Americans, including differences in health in Asian American couples. It is important cultural and gender discourses and the pressure to understand factors that impact Asian American to be a model minority. East Asian cultures are couples, since the Asian American population traditionally influenced by Confucian values, grew four times faster than any other racial group which emphasizes patriarchy and collectivism between 2000 and 2010 (Hoeffel, Rastogi, Kim, (Lee & Mock, 2005), and this lends itself toward & Hasan, 2012). Similar to research on Hispanic women being more submissive to men and fulfill- couples, there have been few studies that look at ing traditional gender roles (Kim, Bean, & specific relationship health variables that are Harper, 2004; Yu, 2011). However, it is important directly related to Asian American culture. to note that it should not be assumed that couples ChenFeng, Kim, Wu, and Knudson-Martin want to inherently subscribe to traditional values, (2017) discuss multiple relationship variables and this is something that should be discussed specific to Asian American couples that they with couples. This is especially the case when apply in couples therapy. The socioemotional working with second-generation Asian cultural variables that they identified throughout Americans, as they likely adopt both their par- their clinical work that are specific to Asian ents’ collectivist values, while also identifying American couples include quiet fortitude/not with individualistic American values (Kim, burdening others, duty to family, and intangible Knudson-Martin, & Tuttle, 2014). Another factor loss. First, the authors discuss how a quiet forti- that therapists should consider when working tude refers to people silently enduring emotional with Asian American couples is the pressure they pain and challenges, without informing their face to be a “model minority,” which refers to partner of these difficulties. Asian American cou- being more academically, economically, and ples have been specifically noted to not want to socially successful compared to other minority burden others with their own emotional pain, racial groups (Yoo, Burrola, & Steger, 2010). since this lines up with their collectivist values of This concept ends up placing high standards on putting others before one’s self. Along with not Asian Americans while also overlooking other burdening others, Asian Americans’ values inequities and ongoing struggles that Asian regarding duty to family support collectivist val- Americans may be experiencing (Ngo & Lee, ues. When considering the relationship among 2007). the couple dyad, Asian Americans may also place Research has also looked at how acculturative a high importance on children and other family stress impacts the relationship quality of Asian members, and this is something to consider in American couples. Hou, Neff, and Kim (2017) therapy. Finally, intangible loss refers to emo- found that lower levels of language acculturation tional disconnection from multiple losses that were associated with higher levels of stress over couples or families experience, including immi- being stereotyped as a foreigner. This foreigner gration trauma, disconnection from family in stress was then related to both positive and nega- another country, loss of their native language, an tive relationship effects. First, Asian Americans’ inability to communicate effectively with their individual foreigner stress was directly related to parents due to language barriers and intergenera- greater levels of their own and their partners’ tional cultural differences, or experiences of dis- marital warmth, which suggests that foreigner crimination in America. The authors describe stress may have a positive relational effect. The how these losses were intangible because they authors discussed how increased warmth was an were not easy to identify, and instead they often outcome only when one partner had high for- came up subtly in therapy and were not acknowl- eigner stress, but the other partner experienced edged by couples. low levels of stress. The authors explained this 438 K. M. Lindahl and S. Wigderson positive effect by suggestion that external stress- ity (Cobell Dagley et al., 2012). However, ors may not always be harmful to relationships, increased levels of coming to terms with this and instead it may mobilize couples’ coping adversity buffered the negative effects, such that efforts as a team. At the same time, individuals’ those who had come to terms with adversity were foreigner stress was associated with increases in significantly more likely to report higher rela- their own depressive symptoms, which predicted tionship quality despite difficult childhood expe- higher levels of their partners’ marital hostility. riences. The authors suggested that coming to The authors discuss how complex language terms with adversity may be an important factor acculturation and foreigner stress are when relat- to consider when treating American Indian cou- ing them to marital quality and that foreigner ples. In another quantitative study, Gray et al. stress may spill over into the marriage. Overall, (2013) compared how early parent-child and there are many factors to consider when treating family relationships affected adult children’s Asian American couples, and it is necessary for relationship quality in American Indian couples therapists to consider a range of factors that may compared to Caucasian couples. Results sug- differently impact each couple. gested that American Indian people generally reported lower ratings on family-of-origin quality and relationship stability measures compared American Indian Couples to Caucasian couples. The authors suggested that historical trauma may explain these differences, Many studies suggest that the American Indian with American Indians experiencing more trauma couples are at particular risk for unhealthy rela- and adversity and this leading to diminished relationship outcomes due to the colonization of tionship stability across multiple generations. American Indian people in the United States The authors also found that the perceived rela- (BigFoot & Funderburk, 2011; Cobell Dagley, tionship between parents and the mother-child Sandberg, Busby, & Larson, 2012; Whitbeck, relationship influenced both Caucasian and Adams, Hoyt, & Chen, 2004; Whitbeck, Walls, American Indian young adults’ relationship qual- Johnson, Morrisseau, & McDougall, 2009). ity when young adults rated their family of origin Furthermore, American Indian couples also expe- as more impactful. Similar to Cobell Dagley rience a high prevalence of historical trauma due et al. (2012), Gray et al. (2013) suggest that com- to loss of lands, culture, spirituality, family prac- ing to terms with negative aspects of their family tices, and language (Gray, Shafer, Limb, & of origin may be the most impactful when trying Busby, 2013). American Indian people also have to improve romantic relationships. a high rate for adversity, including witnessed vio- Given the adversities and trauma that lence, major childhood events, traumatic news, American Indian people experience, it is neces- and death of a parent or siblings (Whitesell, sary to understand what factors may promote Beals, Mitchell, Manson, & Turner, 2009). These American Indian relationship health. Rink, factors are particularly important to consider Ricker, FourStar, and Hallum-Montes (2018) when it comes to American Indian couples, since conducted interviews with American Indian peo- trauma and adversity can have a significant ple to investigate the characteristics and behav- impact on relationship functioning (Cobell iors that promote healthy relationships among Dagley, Sandberg, Busby, & Larson , 2012). American Indian couples. The key themes that There is little research on the specific factors emerged from these interviews included learning that impact American Indians’ relationship qual- about healthy relationships from elders, demon- ity. In a quantitative study that examined how strating mutual respect and trust, showing childhood adversity (e.g., physical abuse, sexual respect for women, and honoring a balance abuse) was related to relationship quality, between love and sex. The findings from this researchers found that childhood adversity sig- study also suggested that American Indian cou- nificantly negatively impacted relationship qual- ple relationships could be strengthened from 30 Cultural Considerations in the Context of Romantic Relationships 439 interventions for American Indian men that rein- Same-Sex Couples force Native beliefs, values, and practices. This includes understanding the kinship and family Most research to date that examines relationship systems that are a part of American Indian cul- functioning in same-sex couples has tended to ture through speaking to their elders. Skogrand find that these romantic relationships generally et al. (2008) also interviewed 21 Navajo couples are very similar to heterosexual relationships. in a qualitative study on what makes Navajo Same-sex and heterosexual couples report simi- marriages strong. These couples identified mul- lar levels of intimacy, conflict, relationship com- tiple factors, including maintaining communica- mitment, and overall level of satisfaction tion, learning about marriage through advice (Kurdek, 2004a; Markey, Markey, Nave, & from family members and observing other cou- August, 2014). Social support from family pro- ples, learning from spiritual leaders and elders, motes individual well-being in same-sex couples and having a strong foundation through shared as well as it does in heterosexual couples, and values and goals. support from one’s partner serves a protective When working with American Indian couples, function from the negative effects of stress for Lettenberger-Klein, Fish, and Hecker (2013) sug- both types of couples as well (Graham & Barnow, gest multiple ways in which therapists can 2013). Support from family members was only enhance their therapeutic relationship with cli- related to relationship quality for heterosexual ents. They suggest that understanding religion couples, perhaps because family members of and spirituality relative to American Indian peo- gays and lesbians may be less likely to approve of ple may be particularly important, since healing their relative’s relationships than the family can occur through these beliefs. The authors pro- members of heterosexual couples (Peplau & vided the example of using a cultural genogram Fingerhut, 2007). Family members who are or spiritual ecomap to map out families’ spiritual- uncomfortable with the sexual orientation of one ity and relationships. Furthermore, the authors of their relatives may overtly devalue the rela- suggest that folktales and stories can be used as a tionship through critical or disparaging com- teaching method of relationship skills, since they ments (Green & Mitchell, 2008). In turn, this can provide culturally sound ways to understand and exacerbate internalized homonegativity which relate to problems in one’s relationship. If thera- can have a negative impact on the relationship pists do not feel educated in utilizing these meth- (Graham & Barnow, 2013). Creating a “family of ods, Lettenberger-Klein et al. (2013) suggest choice” can be very important for many same-sex consulting with elders and tribal leaders and couples if their family of origin is not accepting, helping healers to discuss how cultural stories and this may be why Graham and Barnow (2013) can be integrated into therapy. When working found support from friends to be related to rela- with American Indian people, Brucker and Perry tionship quality for same-sex but not different- (1998) suggest that more direct approaches to sex couples. therapy can clash with American Indian culture, How conflict is expressed also shows similari- given that there is a cultural preference for nondi- ties between same-sex and heterosexual couples. rective communication style. Therefore, it may The demand-withdrawal interaction pattern is a be important for therapists to spend ample time commonly occurring communication dynamic working on their rapport with couples and to whereby the demander complains, nags, or criti- avoid asking their clients for personal informa- cizes and the withdrawer avoids, ends, or with- tion until sufficient rapport has been established. draws from the interaction (Christensen, 1988). There are a multitude of factors to consider when High levels of demand-withdraw are frequently working with American Indian couples; however, found in distressed relationships, including same- further research is needed to examine additional sex couples (Baumcom, McFarland, & unique factors that impact American Indian rela- Christensen, 2010; Kurdek, 2004b). As is found tionship quality. with heterosexual couples, same-sex couples 440 K. M. Lindahl and S. Wigderson tend to be more demanding and engage in less tity (Frost, 2011; Kuyper & Fokkema, 2011). withdrawal when the conflict topic is a subject of Although over the past couple of decades atti- their choosing (rather than a partner-selected tudes have begun change and same-sex marriage topic). became legal in all 50 states in 2015, stigma and Numerous studies show that negative behav- discrimination are still encountered by many gay iors that occur during conflict discussions are and lesbian people. Encountering minority stress- strongly associated with marital dissatisfaction in ors such as prejudice or stigma can make it diffi- heterosexual couples. Studies have begun to cult for same-sex couples to fully meet their emerge replicating this finding with same-sex emotional needs (Meyer, 2003), and stigma and couples. Julien, Chartrand, Simard, Bouthillier, lack of social support have been shown to be and Begin (2003) found negative as well as posi- linked with lower relationship satisfaction tive behaviors in conflict discussions to predict (Belous & Wampler, 2016). Negative stereotypes, relationship quality in lesbian, gay, and hetero- daily hassles or harassment, feeling devalued, sexual couples. The three types of couples also and feeling misunderstood or not accepted by exhibited similar levels of emotional support fol- others all can negatively affect relationship qual- lowing positive couple discussions. The three ity and relationship satisfaction (Frost & Meyer, types of couples also were similar to one another 2009). Frost (2011) found that for some couples, in the extent to which communication behaviors stigma acted as a “negative weight” bearing down were related to relationship quality. on the relationship or as a “contaminant” that Very few studies exist that test the effective- diminished or spoiled otherwise positive couple ness of empirically tested marital therapy pro- experiences. grams for same-sex couples. A study by Garanzini Although associations between stigma and et al. (2017) is a rare exception, and this study relationship functioning are common in the liter- reported on outcome data for gay and lesbian ature, most same-sex couples nonetheless sur- couples receiving the Gottman Method Couples vive, and many thrive. In order to better Therapy (average number of sessions = 8 to 11). understand how this might be the case, Rostosky, In addition to improving communication and Riggle, Gray, and Hatton (2007) interviewed conflict management skills, this intervention also same-sex couples about how they coped with contained units on friendship and intimacy. This stigma. These researchers found that successful study found impressive effect sizes (Cohen’s same-sex couples used strategies such as posi- d > 1), about double that for studies with hetero- tively affirming their relationship and reframing sexual couples and in the large to very large effect negative experiences as empowering experiences. size range for marital satisfaction. The authors Couples who are able to make positive meaning hypothesize that one of the reasons why the out of these experiences seem to be able to per- Gottman approach was so effective for the same- ceive the discriminatory experiences as opportu- sex couples is that same-sex couples generally nities to strengthen or enhance their relationship function better than heterosexual couples due to (Frost, 2011, 2014). smaller gender role differences and less inequal- Knoble and Linville (2012) describe “out- ity. Couples therapy may be more effective with ness” as a “developmental skill” and as an expres- same-sex couples than heterosexual couples due sion of identity as well as a resilience strategy for to the socialized similarities with regard to gen- managing discrimination and gay-related stress. der roles and shared communication styles. Findings are mixed as to what extent outness is Although same-sex couples share many simi- associated with relationship satisfaction, though larities with heterosexual couples, several issues Knoble and Linville (2012) hypothesize that it is also have been identified that are unique to them. not the absolute level of outness that matters as Perhaps one of the more commonly occurring much as satisfaction with level of outness and challenges facing couples in same-gender rela- support partners are able to offer each other that tionships is how to navigate a stigmatized iden- matters most. Balsam, Beauchaine, Rothblum, 30 Cultural Considerations in the Context of Romantic Relationships 441 and Solomon (2008) found outness to be one of ing legal. Balsam et al. (2008) found being in a the predictors of relationship quality for gay men, civil union longitudinally predicted relationship but not lesbians, in a 3-year longitudinal study. stability as couples in civil union were less likely As the authors note, the ability to be more open to have ended their relationship than those not in about one’s relationship may be particularly a civil union after 3 years. important for gay men who face more obstacles It is important to note that legal relationship to being out than lesbians. recognition does not, however, eliminate minor- Outness appears to be a significant consider- ity stress or stigma associated with being in a ation for gay and lesbian couples, even if it is not same-sex relationship (Riggle et al., 2010). always a direct predictor of marital quality. It will Although the impact of legalizing same-sex mar- be important for clinicians not to make assump- riage in the United States is not yet known, tions about how outness influences couple well- Eskridge and Spedale (2006) reported that many being or how much “outness” a couple needs. married same-sex couples in Denmark continued Rather, clinicians would be advised to explore to experience social prejudice and family rejec- the meaning of outness for the couples they are tion even after gay marriage was legally recog- working with and how it influences their relation- nized. In a similar vein, Todosijevic, Rothblum, ship. Knoble and Linville (2012) argue that out- and Solomon (2005) found couples in civil ness is to be encouraged, but given its links to unions in Vermont reported significant stress safety, clinicians need to be mindful of their cli- from family reactions to their sexuality. ents’ need to balance feeling of safety, ability to Many studies have found same-sex couples to manage gay-related stress, and outness. The report more positive relationship quality and less authors offer specific guidance on how to conflict than heterosexual couples (Balsam et al., approach these topics with clients in their 2008; Kurdek, 2004b). As Balsam and colleagues article. note, due to variable support received from soci- Over the past decade, there has been a signifi- ety and family members, same-sex couples may cant societal shift on how same-sex couples’ rela- be held together by their own will and the work tionships are viewed, culminating in the historic they put into making the relationship work. 2015 Supreme Court decision to legalize mar- Rostosky and Riggle (2017) reviewed 66 studies riage for gay and lesbian couples (Garanzini conducted from 2000 to 2016 to identify strengths et al., 2017). This cultural change leaves clini- within lesbian and gay relationships and identi- cians with the challenge of how to meet the grow- fied three relationship processes and four positive ing need of same-sex couples for counseling, relationship characteristics. The three positive guidance, and therapy (Filmore, Baretto, & relationship processes included respecting and Yasasi, 2016). Being in a relationship with legally appreciating individual differences, generating recognized status is associated with less psycho- positive emotions and interactions, and effec- logical distress and greater well-being than being tively communicating and negotiating. The four single or in a dating relationship (Riggle, positive relationship characteristics included per- Rostosky, & Horne, 2010). In a study conducted ceived intimacy, commitment, egalitarian ideals, in Canada with 26 married lesbian and gay cou- and outness. In comparison to heterosexual, mar- ples after Canada passed the Civil Marriage Act ried couples, Kurdek (2005) found same-sex in 2005, couples showed significantly higher lev- partners to divide up household chore more els of relationship satisfaction and less evenly and to resolve conflict more construc- attachment-related anxiety compared to norms tively. In a 12-year longitudinal study, Gottman for heterosexual couples (MacIntosh, Reissing, et al. (2003a, 2003b) found same-sex couples to & Andruff, 2010). Qualitative interview data be less defensive and less domineering and to from this study also indicated that couples felt show greater humor during conflict discussions validated and legitimized and were more likely to than heterosexual married couples. It may be that be out as a consequence of gay marriage becom- partnering with a person of the same sex confers 442 K. M. Lindahl and S. Wigderson unique benefits such that both members of the https://healthymarriageandfamilies.org/content/ couple are socialized similarly with respect to working-african-american-individuals-couples- gender roles and they may share similar commu- and-families nication styles. For clinicians working with Program for Promoting and Strengthening same-sex couples, in addition to helping them African American Marriage: http://prosaam.uga. overcome relationship challenges, it also seems edu imperative to help couples identify or build areas http://www.healthymarriageinfo.org/research- of strength, especially in the above areas. policy/marriage-facts-and-research/marriage- In sum, in this chapter, we have attempted to and-divorce-statistics-by-culture/african-americans- summarize some of the major challenges and and-black-community/ threats to relationship well-being across a diverse range of couples. We also have tried to highlight important areas of strength for couples that ther- References apists can help clients enhance. Group differences found in the literature, however, do not Ajrouch, K. J., Reisine, S., Lim, S., Sohn, W., & Ismail, mean all couples within a particular ethnic group A. (2010). 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A facilitators to treatment (see Behavioral health ACA Code of Ethics, 28 services) Acceptance and Commitment Therapy (ACT), 6 subjugation and enslavement, 112 Acceptance-based model, 235 African/Black diaspora, 259–262 Acceptance commitment therapy (ACT), 221 Afrocentric values, 123 Accessibility, 46 Aggressive and agitated behavior, 372 Accommodated Cognitive-Behavioral Treatment Agoraphobia, 272 (A-CBT), 409, 410 Alcohol intoxication, 407 Acculturation, 42–44, 185, 186 Alcohol-related disorders, 407 Acculturative stress, 186–188, 333 Alcohol-related substance use disorders, 404 Achenbach System of Empirically Based Assessment Alogia, 374 (ASEBA), 423 Alternative services Adapting therapeutic approach, 387 Asian Americans, 137–138 ADDRESSING model, 79, 80 American Academy of Family Physicians, 326 Adjustment to disability, 223, 226 American Academy of Sleep Medicine (AASM), 326 disability-related changes, 218 American Association of Marriage and Family Therapists disability vs. family members, 218 (AAMFT), 26, 27 factors, 218–219 American Counseling Association (ACA), 26–28 individual vs. family, 219–221 American Indian Service Utilization, Psychiatric people’s daily functioning, 218 Epidemiology, Risk and Protective Factors quality of life, 218 Project (AI-SUPERPFP), 310 Adverse childhood experiences (ACEs), 424 American minority community, 288 Affordable Care Act, 117 American Psychiatric Association (APA), 1, 26, 27, 338, African Americans 339, 348, 363, 403, 406 African slave population, 259 American Society of Addiction Medicine (ASAM), 413 barriers to treatment Anhedonia, 374 cultural mistrust, 117, 118 Anxiety, 67 insurance factor, 117 Anxiety disorders, 114, 272, 277, 294 medication issues, 118–119 cultures race and ethnicity, 117 adaptations, 280 treatment engagement, 118 cognitive-behavioral therapies, 279 discrimination and racism, 111 culture-specific syndromes, 279 disorders effective evidence-based behavioral, 279 ADHD, 116 effectiveness of standard treatment ASD, 116 approaches, 280 CD, 116, 117 European American patients, 279 eating disorders, 115 intervention approaches, 280 GAD, 114 minority ethnic/racial and cultural groups, 279 MDD, 113, 114 obsessive-compulsive disorder, 279 obesity, 115 PTSD studies, 279 OCD, 114 sensitive assessment and treatment, 280 PD, 114 short-term and time-limited curricula, 280 psychotic disorders, 112, 113 social contextual factors, 279 PTSD, 115 variety of somatic sensations, 279

Anxiety disorders (cont.) Behavioral health, 64, 71, 111 Latinx individuals Behavioral health assessment adult primary care patients, 278 cultural biases, 55 clinical researchers, 277 cultural variables, 57 clinical trials research context, 278 measurement errors, 55 (see also Standardized emotional and social distress, 278 assessments) epidemiological studies, 277 translation and adaptation, 55–56 ethnic groups, 278 validity, 54 mental health symptoms, 278 Behavioral health evaluation, 53 psychological disorders, 278 Behavioral health service delivery racial and ethnic minority primary care cultural barriers, 200 patients, 278 culturally responsive, 203, 204 Anxiety-related symptoms, 277 evidence-based practices, 204–205 Applied relaxation (AR), 237–238 language, 203 Ascetic syndrome, 349 structural barriers, 198–200 Asian Americans, 335 Behavioral health services cultural relevance, 131 African Americans disorders afrocentric values, 123–124 anxiety disorder, 133 biological factors for families, 119–120 brain illnesses, 132 building trust and rapport, 121–123 diagnosable mental disorder, 133 check-ins and review of progress, 125 physical health disorder, 137 provider and treatment transparency, 119 sleep disorders, 137 religious and traditional healing practices, 124–125 ethnic matching, 133, 134 sociocultural considerations, 120 face concern, 139 treatment environment, 120–121 invisibility, 131 Asian Americans loss of face, 139 alternative services, 137–138 population, 131 client ethnicity and therapy techniques, 138 Asian diaspora, 250–252 cultural adaptations, 135–136 Asociality, 373 cultural competence, 135 Assertive community treatment (ACT), 393, 394 cultural relevance, 138 Assessments ethnic matching, 133–134 forensic setting, 70 federal behavioral health policies, 131–132 mood disorders SPST, 137 anxiety, 67 underutilization of treatment, 132–133 learning disability, 69, 70 Latina/o/x neurocognitive, 68 language interpretation services, 167 personality, 68 non-stigmatizing way, 170 psychosis, 68 therapy, 170–173 translated measures, 67 LGBT psychometrics CBT, 180 normative sample, 66 clinical principles and techniques, 181 reliability, validity and utility, 66–67 UCR, 178 substance-related disorders Behavioral health specialist, 412 intervention helpfulness, 408 Behavioral problems in children substance use disorders bidirectional relationship, 419 diagnostic, 406 cultural stress, 421 progress and outcome, 407, 408 discipline strategies, 420, 421 screening measures, 405, 406 disruptive behaviors, 419 Attention-deficit hyperactivity disorder (ADHD), 116, 422 and emotions, 419 Authenticity, 121 factors, 419 Autism spectrum disorder (ASD) parenting style, 420 African American children, 116 poor emotion regulation/distress tolerance, 419 Avolition, 374 prevalence and diagnosis, 422, 423 sociological/spiritual etiology, 419 standardized assessment systems, 423 B trauma exposure, 424 Behavioral activation (BA), 5, 313 treatment Behavioral approach, 236 childhood behavior problems, 424 Behavioral engagement strategies, 241 disruptive behaviors, 424 Index 449

parent-child therapies, 425, 426 defined theoretical model, 76 parent management training, 425 empathy, 77 trauma-focused therapy, 426 expectations, 77 Behavioral Risk Factor Surveillance System (BRFSS), 312 genuineness, 77 Beliefs, 47 learning theory, 75 Bicultural/acculturative stress, 421 positive regard, 77 Black Africans, 259 rapport building (see Rapport building) Black Americans, 111, 112, 332, 333 specific ingredients, 77 Black ethnic minorities, 365 theories of personality, 75 Blacks and African-Americans, 262 therapeutic alliance, 76 Blunted affect, 374 therapies, 75 Body dysmorphic disorder (BDD), 301 therapist factors, 77 Body mass indexes (BMIs), 333 Wampold’s contextual model, 76 Brief Negative Symptom Scale (BNSS), 383 Community based participatory research (CBPR) 2000 British National Psychiatric Morbidity Survey, 294 design, 151 Bronfenbrenner’s ecological systems model, 63 Community-based participatory research (CBPR) Building rapport approach, 288 African Americans, 122 Community-centered evidence based practice model, 205 Community Health Center, 285, 286 Community Mental Health Centers (CMHC) Act, 131 C Conduct disorder (CD) California Evidence-Based Clearinghouse’s Scientific in African Americans, 116, 117 Rating Scale (CEBC), 105 Conscience clause, 32 Catatonia, 373 Contact theory, 191 CBT in group format (CBGT), 273, 274 Contemporary common factor models, 77, 78 Center for Collegiate Mental Health, 312 Contextual behavioral science (CBS) Center for Disease Control (CDC), 312 behavioral health and change, 78 Center for Disease Control and Prevention, 323, 324 behavioral phenomenon of interest, 83 Center for Epidemiological Studies Depression Scale centered, open and engaged response styles, 84, 85 (CES-D), 56, 249 cultural considerations, 81 Child Abuse Potential Inventory (CAPI), 424 definition, 82 Child Behavior Checklist (CBCL), 423 interpersonal style, 88 Child Protective Services (CPS), 154 PFM, 83, 86 Chronic health problems, 323 principles, 81 Chronic neuropsychiatric disorder, 293 psychological flexibility, 87 Client compliance therapeutic relationship and therapeutic and intervention helpfulness, 408 procedure, 78 Clinical Assessment Interview for Negative Symptoms Contingency management, 409 (CAINS), 383 Counseling competence Clinical guidelines, 274 cross-cultural, 13 LGBT, 181, 182 multicultural, 13 Clinical practice, 27, 28, 30, 35 Couples Clinician biases, 118 African American Cognitive avoidance theory, 234 anger and aggression, 433 Cognitive-behavioral group therapy (CBGT), 283 benefits of marriage, 431 Cognitive-behavioral therapy (CBT), 96, 99, 102, 155, contextual factors, 432 273, 274, 277, 297, 313, 314, 332, 335, 352, deficit/problem-oriented model, 433 354, 388 environmental stressors, 433 Asian Americans, 136 ethnicity and race, 432 LGBT clients, 180–181 factors, 432 Cognitive behavioral therapy for insomnia (CBT-I), financial strain, 432 326, 327 financial stress and marital functioning, 432 Cognitive Behavioral Therapy for Psychosis (CBTp), longitudinal associations, 432 388, 390 marital dissatisfaction, 432 Cognitive remediation, 392 quality of daily interactions, 432 Cognitive restructuring (CR), 236–237 race and racial discrimination, 433 Collateral interviews, 59 race-based stressors, 433 Common factors racial discrimination, 433 CBS, 76 religiosity and spirituality, 434 and cultural considerations, 82 spillover models, 432 450 Index

Couples (cont.) imperative, 15 American Indian, 438, 439 interdependent constructs, 14 Asian American, 437 limitations assessment, 436 description, 4 Hispanic American, 435, 436 family caregivers (see Family caregivers) same-sex (see Same-sex couples) Jewish clients (see Jewish clients) treatment, 433 MBCT, 5 Critical and judgmental approach, 240 MBSR, 5 Cross-cultural competence, 15 mental health conditions, 5 Cross-cultural counselling competency, 13 Native Americans (see Native Americans) Cross-cultural similarities, 302 outcomes, 7 Cultural PLG, 5 adaptation, 58 practice competencies, 19 biases, 55 racial and ethnic minority individuals, 1 cross-cultural comparisons, 56 three-dimensional model, 1 culturally adapted interventions, 106 (see also Cultural considerations, 79–82, 84–86, 88 Empirically supported treatments (ESTs)) cultural competency (see Cultural competency) culturally diverse, 53 (see Sleep disorders) identification, 65 substance use disorders (see Substance use disorders) intelligence, 54 Cultural desire, 14, 16 multiple methods approach, 59 Cultural diversity, 13, 18 normative scores, 56–57 Cultural encounters, 14, 16 psychological assessment (see Assessments) Cultural factors response biases, 55 assessment, 405–408 socio-cultural context, 59 integrated behavioral health care, 411–413 socioeconomic status, 65 Cultural formulation interview (CFI), 377, 406 variables, 54, 57, 58 Cultural humility, 17, 20 western industrialized, 54 Cultural identities, 16 Cultural adaptations, 3–4, 16, 17, 76, 77, 79, 82, 88, Cultural immigrations, 148 315, 317 Culturally adapted evidence-based therapy, 388–389, 394 African American adolescents, 410 Culturally adapted interventions, 106 Asian Americans, 135–136 Culturally adapted therapy behavioral treatments, 409 community, 151 definition, 135 cultural approach, 151 evidence-based treatments, 414 evidence-based treatment, 151 Latina/o/x, 170 mental health services, 151 psychosocial treatments, 409 Native Hawaiian, 150 SSICECTS, 410, 411 Pacific Islanders, 150 treatment, cultural groups, 408–410 Culturally competent, 14 Cultural approach, 151 Culturally competent care, 117 Cultural attunement, 17 Culturally Competent Community Care (CCCC) model, 14 Cultural-bound syndromes, 348, 349 Culturally responsive, 198, 203, 204, 206 Cultural care theory, 12, 13 Culturally responsive approach, 233, 239 Cultural competence training, 18 Cultural mistrust, 117 Cultural competency, 15, 16 Cultural responsiveness, 17, 134 acculturation and immigration status, 2 ADDRESSING framework, 233 Asian Americans, 135 AR, 237–238 attributes, 15 emic approaches, 233 and benchmarks, 18, 19 etic approach, 233 constructivist definition, 16 evidence-based practices/resources, 233 criticism, 20 GAD treatment, 232, 234 cultural adaptation, 16 RESPECTFUL model, 233 culturally competent practitioners, 2, 3 Cultural safety, 17 definitions, 12–16 Cultural sensitivity, 14, 17, 20, 122 elements, 19 Cultural Sophistication Matrix, 14 ethical and epidemiological considerations, 2 Cultural stress, 421 existing measures, 20 Cultural tailoring, 17 guidelines and training, 2 Cultural Treatment Adaptation Framework (CATF), 71 health care delivery, 11 Cultural values and health care disparities, 19 African American, 118, 120, 123 Index 451

Culture, 433, 435–437, 439 impaired control, 406 African Americans pharmacological effects, 407 anorexia, 115 risky behavior, 407 competent care, 117 SCID, 406 cultural mistrust, 112, 113, 117 social impairment, 406 cultural relevance, 118 Diagnostic decision making, 64, 67 culturally influenced symptoms, 114 Diagnostic Interview Schedule (fourth version) in client relationships, 79–80 (DIS-IV), 382 definitions, 79 Dialectical behavioral therapy (DBT), 156, 221, 286, 410 Culture-based education strategies, 148 Diminished expressivity (EXP), 373 Culture Brokerage, 13 Disability Culture-related diagnostic issues, 377, 381–383, 394 ADA, 211 Culture-specific coping method, 387 adjustment (see Adjustment to disability) Culture-specific practices method, 387 identity and self-concept, 215–216 Culture-specific strategies, 387 language Current trends, 12 belief and expectations, 214–215 Customs and Border Protection (CBP), 203 clinicians, 212 learning, 212 mental health, 212 D use and diagnosis, 213–214 Deferred Action for Childhood Arrivals (DACA) mental health, 211 program, 33, 203 personal and societal barriers, 217 Delayed ejaculation (DE), 353, 354 professionals, 211 Delusions, 367, 368 therapeutic techniques (see Therapeutic techniques) Depersonalization, 256, 257 time and support, 227 Depression, 282 Discrimination of stress, 394 advantage, 316 Disorganized symptoms application, 316 behavior, 371–373 commonalities, 315 disorganized thinking, 370, 371 communities, 317 Disparities contextual factors, 313 in health, defined, 93 economic burden, 309 mental health, 93, 94 effectiveness of treatments, 314 in substance use treatment, 405 epidemiological research, 310, 313 Disruptive behaviors, 419, 423–426 family context, 313 Diverse clients, 25, 31, 32 gender, 312 Diversity, 2, 3 generational status and acculturation, 311 Diversity competence, 15 heterogeneity, 316 Drinking behavior, 55 intersectional approach, 317 intersectionality approaches, 316 mental health services, 315 E mental healthcare, 316 Eating disorders (EDs), 284 national origin, 310 Asian Americans, 335 psychiatric care, 309 Black Americans, 332, 333 psychosocial and pharmacologic treatments, 309 body image and dissatisfaction, 331 psychotherapy, 309 chronic duration, 331 racial and ethnic minorities, 309, 313–315 comorbid psychopathology, 331 racism and sexism, 316 culture-bound, 332 SES, 311, 312 diverse demographic groups, 332 sexual and gender minorities, 312 diverse groups and populations, 332 social and family relationships, 313 evidence-based treatments, 331 US general population, 309 family-based therapy, 331 within-group variability, 313 Latinx Americans, 334, 335 Derealization, 256, 257 medical complications, 331 Dhat syndrome, 348 minority populations, 332 Diagnostic and Statistical Manual of Mental Disorders racial/ethnic minorities, 332 fifth edition (DSM-5), 381, 406, 422, 423 risk factors, 331 Diagnostic assessment, substance use disorders substantial psychosocial impairment, 331 culture-related, 407 variety of populations, 332 DSM-5, 406, 407 weight stigma, 331 452 Index

Emic approaches, 233 F Emotional coping strategies, 241 Faafaletui Model, 156 Empathy, 76, 77 Face, 102 Empirically supported treatments (ESTs) Face concerns, 103 clinical strategies, 99 Face loss, 102 cognitive therapy and time-limited dynamic Face Loss Questionnaire, 103 psychotherapy, 102 Faith-adapted cognitive-behavioral interventions CPA, 106 (F-CBT), 192 culturally adapted, 95–97 Family-based therapy, 331 culturally sensitive, 104 Family caregivers, 4 description, 94 Family context, 313 effects, mental health problems, 94 Family psychoeducation approaches, 392, 394–395 limitations, 94, 104, 106 Family support, 101 minority adolescents and children, Federally Qualified Health Centers (FQHCs), 157 104–105 Female orgasmic disorder (FOD), 354 minority youth, 105 Female sexual interest/arousal disorder (FSIAD), 354, 355 Engagement, 18 Forensic setting, 70 Epidemiologic Catchment Area (ECA) Forgiveness, 222–224 program, 294 Functional analytic psychotherapy (FAP) Epidemiology for African American clients, 121 acculturation, 42 Functional contextualism, 83 ethnic status in SES, 40 social causation and selection, 39 Erectile disorder/dysfunction (ED), 352 G Ethical codes, 25–28, 32 Gender, 312 Ethics Gender-Related Diagnostic Issues, 377 ACA Code of Ethics, 28 Generalized anxiety disorder (GAD), 114, 282 cultural neutrality, 27 cross-cultural measurement biases, 232 ethical dilemma cases, 25, 30, 33–35 cultural competency and responsiveness multicultural competence, 27 (see Cultural responsiveness) multicultural ethical competence (see Multicultural ethnic minorities, 232 ethical competence) fear and related behavioral disturbances, 231 professional codes, 26–27 immigrant, 232 Standard 6.04 Social and Political intervention Action, 28 acceptance-based model, 235 Ethnic identity AR (see Applied relaxation (AR)) definition, 165 conceptual models, 235 Ethnic match, 95 CR (see Cognitive restructuring (CR)) Ethnic minorities, 46, 326 WE (see Worry exposure (WE)) Ethnic minority clients, 97, 99, 103, 107 mindfulness and acceptance-based approaches Ethnic sensitive social work practice, 13 (see Mindfulness and acceptance-based Ethnicity, 323, 324, 327 approaches) Ethnoracial trauma, 202, 203 racial/ethnic and sexual minorities, 232 Ethnosensitivity, 13 symptoms, 231 Etic approach, 233 treatment, 239 European Americans, 112–116, 121 Generalized Anxiety Disorder Test (GAD-7), 57 Evidence-based Genito-pelvic pain/penetration disorder, 355 behavioral substance use treatments, 403 Genuineness, 76, 77, 88 culturally adapted interventions, 155 Gordibuena, 334 management of cultural factors, 403 Gottman Method Couples Therapy, 440 practices, 204, 205 SSICECTS, 403 therapy, 284 H Evidence-based treatments (EBTs), 333 Hair-pulling disorder, 301 Asian Americans, 132, 135, 136 Hair sample analysis, 407 LGBT clients, 180–181 Hallucinations, 368, 369 Evidence-supported treatments, 411 Hamilton Anxiety Scale, 282 Excessive thinking, 47 Harvard Trauma Questionnaire (HTQ), 249 Excoriation disorder, 301 Health disparities Exposure and response prevention (ERP), 297 Asian Americans, 132, 133, 138 Index 453

Healthy immigrant paradox, 311 narratives, 45 Healthy rapport, 77 research, 45 Heart disease, 323 self-stereotyping, 45 Help-seeking behaviors, 295, 296 Intersectionality approaches, 316, 317 Heterosexuals, 338 Intervention Hispanic helpfulness and client compliance, 408 politically conservative term, 254 Islam Hispanic/Latinx clients, 258, 259 contact theory and intergroup contact, 190–191 Hispanic/Latinx diaspora, 254–255 interventions, Muslim clients, 192–193 Hispanic Stress Inventory (HIS-2), 258 jurisprudence, 186, 188–190 Hoarding disorder, 301 Muslim immigration, 185 Homosexuality OCD (H-OCD), 298, 299 Human rights violations, 199 Human sexuality, 345 J Hypothalamic-pituitary-adrenal axis (HPA axis), 40 Judaism, 6

I K Immigrant paradox, 42, 43 Koro syndrome, 349 Immigrants, 420, 421, 425 behavioral health service delivery (see Behavioral health service delivery) L culturally responsive, 198 Language, 16, 203 diversity, 197 Latina/o/x ecological framework, 200–202 adaptations to psychotherapeutic content, 171–173 ethnoracial trauma, 202–203 adaptations to psychotherapeutic process, 170–171 learning, 197 discrimination, 165 risk, 198 economic and political factors, 164 Immigration and Customs Enforcement (ICE), 203 ethnic identity, 165, 166 Immigration processes, 201, 202 geography and language, 163 Insomnia, 323, 325 Hispanic, in USA, 163, 164 Insurance factor, 117 history, 163 Integrated behavioral health care humility, 167 ASAM, 413 intake interviews, 167 primary care, 411 assess the centrality, 168 settings, 413 barrier to treatment-seeking, 169 treatment team cognitive-behavioral approaches, 170 administrative and supportive members, 412, 413 modifications, 170 behavioral health specialists, 412 power differential, 167 medical clinicians, 412 sociopolitical stressors, 168 team leader, 411–412 mental health, 165 treatment goals, 413 vs. non-Latinx Whites, 165 Integrated care, 413 stressors, 165 Intercultural competence, 15, 16 treatment, 166 Intergroup contact US population, 163 anxiety, 191 Latinx Americans, 334, 335 and attitudes, 191 Latinx culture-bound syndromes, 257–258 contact theory, 191 Latinx diaspora, 255–257 factors, 191 Latinx population, 271 positive effects, 191 Learning disability, 69, 70 International perspectives, 59 Legal methods, 393 Interpersonal psychotherapy (IPT), 313, 314 Lesbian, gay, bisexual and transgender (LGBT) Interpersonal therapy, 332 birth cohort, 177 Interpreters, 64, 69, 70 body dissatisfaction, 338 Intersectionality, 166 CBT, 180–181 definition, 45 cisgender females, 338 double-jeopardy hypothesis, 46 community, 177 ethnic-prominence hypothesis, 46 ED pathology, 338 identities, 45 ED symptomatology, 339 interplay, person and social location, 45 epidemiology, 44 454 Index

Lesbian, gay, bisexual and transgender (LGBT) (cont.) Mindful Self-Compassion (MSC), 225 gender dysphoria, 339 Mindfulness, 277, 280, 281, 283, 288 guidelines, clinical principles and techniques, 181 Mindfulness and acceptance-based approaches, 236, 239 heterosexuals, 338 behavioral engagement strategies, 241 LGBTQ community, 44 critical and judgmental approach, 240 mental health problems, 339 emotional coping strategies, 241 physical and mental health problems, 339 future-oriented threat, 240 psychological distress (see Psychological distress) mental health struggles, 240 psychosocial stress, 339 physiological and emotional responses, 239 race, ethnicity, immigrant status and sexual transgender, 241 orientation, 44 Mindfulness-based cognitive therapy (MBCT), 5 role of minority stress, 339 MBI protocols, 283, 284 sexual minority group, 338 Mindfulness-based exposure therapy (MBET), 284 sexual orientation, 338 Mindfulness-based interventions (MBIs) spectrum and sexual minority clients, 339 anxiety disorders, 282, 283 suicide rates and tendencies, 44 cultural adaptations, 287, 288 suicide-related characteristics, 44 cultural groups, 289 Licensed professional counselor (LPC), 412 diverse populations, 286, 287 Lifelong learning, 17, 20 MBSR, 280, 281, 284–286 Lifelong process, 12 optimal intervention approach, 288 Loss of semen syndrome, 348 Mindfulness-based stress reduction (MBSR), 5, 221 anxiety disorder, 282, 283 choiceless awareness, 281 M chronic illness/suffering negative health effects, 280 Major depressive disorder (MDD), 41, 43, 113, 114, chronic pain, 281 310, 314 medical and psychiatric conditions, 281 Male hypoactive sexual desire disorder (MHSDD), meditation practices, 281 351, 352 stress reduction curriculum, 280 Males, ED Minority stress theory, 48 adolescence and young adulthood, 337 Model minority, 437 AN and BN, 336 Mood symptoms, 376 body dissatisfaction, 337 Motivation and pleasure (MAP), 373 and female problem, 337 Multicultural competence, 27, 28 muscle dysmorphia, 336, 337 Multicultural Counseling Competency and Planning muscularity-oriented disordered eating, 337 Model (MCCAP), 31 non-purging compensatory behaviors, 336 Multicultural/cultural pluralism, 17 psychiatric disorders, 336 Multicultural ethical competence symptomatology, 336 conscience clause, 32 weight stigma, 337 decision-making models Marijuana use, 178 cultural awareness and service guidelines, 30 Marital distress, 431 ethnocentric approaches, 30 Marital stress, 394 helping professionals, 32 Measurement error, 53–55, 58, 60 MCCAP, 31 Medical clinicians, 412 NLPA, 31 Medication-assisted treatment (MAT, 412 Tarvydas Integrative Model, 32 Mental disorders, 295 violations, 30 Mental health, 211, 212, 214 description, 29 African Americans, 111, 112 ethical contextualism/universalist approach, 29 disparities, 117 ethical decision-making approaches, 29 psychotic disorders, 112 immigration and DACA, 33 race-based, 125 moral framework, 29 services, 117 prescriptive approach to ethics, 28 stigma, 120 virtue ethics, 29 external factors, 111 Multiculturalism, see Multicultural ethical competence needs of Muslim clients, 186 Multiculturally competent, 31, 93 Mental health disparities, 93, 94, 106 Multiple Dimensions of Cultural Competence Mental health issues, 431 (MDCC), 14 Mental health outcomes, 433 Multiple interviews, 59 Mental health symptoms, 256 Multiple methods approach, 59 Metabolic syndromes, 333 Muscle dysmorphia, 336, 337 Metacognitive training (MCT), 390 Muscularity-oriented disordered eating, 337 Index 455

N culturally adapted therapy (see Culturally adapted National Association of Social Workers (NASW), 26–28 therapy) National Comorbidity Survey Replication (NCS-R), definition, 144 294, 310 depression and suicide, 155 National Epidemiologic Survey on Alcohol and Related ecological framework, 154 Conditions-III (NESARC-III), 312 Filipino, 157 National Epidemiological Survey on Alcoholism and Fonofale model, 157 Related Conditions (NESARC), 310 FQHCs, 157 National Health and Nutrition Examination Survey Hawaiʻi (NHANES), 310 Bayonet Constitution, 147 National Health and Social Life Survey, 346 colonization, 147 National Health Interview Survey, 324 culture-based education strategies, 148 National Institute for Health and Care Excellence, 274 inhabitants, 146 2003 National Institute of Health National Sleep language and practices, 147 Disorders Research Plan (NSDRP), 323 medicinal practices, 146 National Latino and Asian American Study (NLAAS), 310 Native Hawaiian, 147 National Latinx Psychological Association prosocial vs. antisocial behavior, 146 (NLPA), 31 traditional diet, 147 National Registry of Evidence-based Programs and incarcerate youth, 156 Practices (NREPP), 283 learning process, 158 National Survey of American Life (NSAL), 310 mental illnesses, 156 Native Americans, 2, 4, 6 Native Hawaiian culture, 148, 150 Native Hawaiian, 144–148, 150, 152–158 political council, 145 Naturalistic testing, 58 Polynesian societies, 145 Negative symptoms, 373, 374 PTSD, 155, 156 Neurocognitive assessment, 68 religious advisors, 145 Neuropsychological tests, 69 Samoan models, 156 Neuroscience, 132 substance abuse treatments, 156 New-generation assessment approaches, 383 therapy, 152, 153 Norm-based approach, 385 traditional Hawaiian society, 145 trauma, 155, 156 values, 154 O wellness/strength based models, 153 Obsessive-compulsive disorder (OCD), 114 Pandanus model, 157 best-practice treatment, 293 Panic disorder (PD), 114, 272, 282 biological model, 302 Parent-child interaction therapy (PCIT), 425 and compulsions, 293 Parent-child therapies, 425, 426 cross-cultural prevalence, 294 Parenting style, 420 cross-cultural significance, 294 Past traumatic experiences, 424 cultural factors, 293 Patient centered care, 18 cultural identity and impact, 293 PC-CARE, 426 culturally adapted assessment measures, 296, 297 Peritraumatic dissociation, 256 descriptions, 293 Peritraumatic panic attacks, 256 help-seeking behaviors, 295, 296 Personality, 68 homosexuality obsessions, 298, 299 Person-first language, 213 individual diversity factors, 299 Physical health issues, 431 multifaceted definition, culture, 303 Physical/sexual abuse, 253 role of religion, 300 Political council, 145 superstitions, 300 Polynesian societies, 145 treatment considerations, 297 Polysomnography (PSG), 326 USA and Abroad, 294, 295 Population-level risk factors, 39 Obsessive-compulsive spectrum disorders Positive regard, 76–78, 88 (OCSDs), 301 Posttraumatic Slave Syndrome (PTSS), 261 Obstructive sleep apnea, 323 Post-traumatic stress disorder (PTSD), 247, 250, 256, 257, 260, 262 African Americans, 115 P Prediction-and-influence, 83 Pacific Islanders Pre-loss grief (PLG), 5 conceptualizations, 158 Premature ejaculation (PE), 353 cultural competency, 152 Problem conceptualization, 98, 99 cultural immigrations, 148 Problem-solving therapy (PST), 313 456 Index

Prosocial vs. antisocial behavior, 146 meta-analytic methods, 78 Proximal-distal model, 94 self-disclosure, 88 coping strategies and problem-solving, Reality distortion symptoms 99, 100 delusions, 367, 368 cultural differences, effects, 98 hallucinations, 367–369 cultural elements, 98 Recruitment strategy, 6 cultural identity, 101–102 Relationships face concern, 102–103 marital, 431 problem conceptualization, 98, 99 marriage and committed, 431 racial and ethnic match, 103–104 quality, 431 treatment credibility, 98 social, 431 treatment goals, 100, 101 Religiosity, 434 Psychiatric disorders, 294, 336 Repetitive/stereotyped behavior, 372 Psychological assessment, see Assessments Resilience, 222, 225, 226 Psychological disorders, 278 Psychological distress, 345 LGBT S anxiety and depression, 177 Same-sex couples marginalized minority group, 177 clinicians, 442 minority stress, 179 communication and conflict management substance abuse, 178–179 skills, 440 suicide, 179 dating relationship, 441 trauma and PTSD, 178 demand-withdrawal interaction pattern, 439 Psychological evaluation group differences, 442 academic/linguistic history, 65 heterosexual couples, 441 cultural identification, 65 heterosexual relationships, 439 initial contact, 64 minority stressors, 440 pre-educational history, 65 negative behaviors, 440 socioeconomic status, 65 outness influences, 441 Psychological flexibility model (PFM), 86–88 positive relationship processes, 441 of behavioral health, 83–85 qualitative interview data, 441 of behavior change, 85–86 resilience strategy, 440 and CBS, 86 social support, 439 as culturally situated behavioral repertoires, 87–88 stigma and relationship functioning, 440 psychosocial treatments, 88 types, 440 therapist training, 88 Samoan models, 156 Psychopathology, 112, 120 Scale for the Assessment of Negative Symptoms Psychosis, 41, 42, 44, 48, 68 (SANS), 383 Psychosocial stress, 339 Scale for the Assessment of Positive Symptoms Psychotherapy (SAPS), 383 Muslim clients, 185, 192 Schedule for Affective Disorders and Schizophrenia relationship, 78 (SADS), 382 Psychotherapy adaptation and modification framework Schizophrenia (PAMF), 107 ACT, 393, 394 CBTp, 388, 390 cognitive remediation, 392 R culturally adapted evidence-based behavioral Race and ethnicity, 41, 44, 45 treatments, 388–389 Racial discrimination, 40, 41, 433 culture-related diagnostic issues, 381 Racial trauma, 115 DSM-5, 381 Randomized controlled trials (RCTs), 282 ethnic and cultural background considerations, 394 Rapid eye movement (REM), 325 family psychoeducation, 391, 392 Rapport functional impairment, 381 description, 77 social learning and token economy programs, 392 and respect, 79 spectrum disorders, 383–387, 394 Rapport building SSOPD (see Schizophrenia spectrum and other cultural considerations, 79, 81 psychotic disorders (SSOPD)) empathy, 77 SST, 390, 391 healthy rapport, 77 supported employment programs, 392 Index 457

Schizophrenia spectrum and other psychotic disorders social factors, 326 (SSOPD) socioeconomic status, 325 assessment Sleep disturbances, 324, 326 diagnostic, 382 Sleep interventions, 137 neurocognition and functional impairment Sleep-related disorders, 324 (see Schizophrenia spectrum disorders) Social and sexual behavior, 372 psychotic symptom, 383 Social anxiety disorder (SAD), 282, 283 treatment African Americans, 272 approach, 387 clients, 274, 275 cultural adaptations, 387–388 cultural groups, 272 culturally adapted evidence-based behavioral Japanese and Koreans, 273 treatments, 388 Latinx population, 271 Schizophrenia spectrum disorders mental illness, 271 cultural factors, 363 quality of life, 271 differential diagnosis, 376 treatments, 273 DSM-5 diagnoses, 375–378 Social causation, 39, 40 ethnic differences, 365, 366 Social-ecological model, 325 gender and age differences, 364 Social factors, 365 global prevalence rates, 364 Social learning and token economy programs, 392 psychotic disorders, 363 Social neuroscience, 136 US prevalence, 363, 364 Social problem-solving therapy (SPST), 137 Screening measures, substance use, Social relationships, 431 405, 406 Social selection, 39, 40 Segregationism, 186 Social skills training (SST), 390, 391 Self-awareness, 12 Social welfare programs, 199 Self-compassion, 222, 224, 225 Sociocultural factors, 365 Self-stereotyping, 45, 46 Socioeconomic status (SES), 151, 311, 312, 420 Semistructured Interview for Consideration of Ethnic and mental disorders, 40 Culture in Therapy (SSICECTS), 403, 410, 411 psychological evaluation, 65 Sexual disorders, 345 race and health, 40 Sexual dysfunction racial minority and majority, 40 acculturation, 350 theory of social causation, 39 assessment, 351 Socioemotional cultural variables, 437 cross-cultural prevalence, 347, 348 Somatic symptoms, 257 cultural practices, 350 Specific ingredients, 76, 77, 86 culturally bound syndromes, 348, 349 Spirituality, 434 cultures, 345 Standardized assessments definition, 345 collateral interviews, 59 DSM-V, 346 international perspectives, 59 evidence-based treatments, 349 multi methods approach, 59 exposure to sexual education, 350 multiple interviews, 59 female circumcision, 351 naturalistic testing, 58 religion, 350 psychometric tests and socio-cultural context, 60 sex and procreation, 350 Stigma sexual health concerns, 349 African Americans, 120 treatment and assessment, 346 definition, 47 Sexual health, 345 excessive thinking, 47 Sexual orientation OCD (SO-OCD), 298 intrapersonal and interpersonal forms, 48 Shenkui syndrome, 349 in mental health, 47 Skills, 12 mental illness, in Chinese society, 47 Sleep disorders minority stress theory, 48 biophysiological changes, 326 nationally representative research, 47 ethnic minorities, 326 race and sexual orientation, 48 health problems, 323 and societal injustice, 46 insomnia, 323 structural, 48 racial/ethnic disparities, 324 Stroke, 323 sleep deprivation, 323 Structural stigma, 48 sleep disturbances, 324 Structured Clinical Interview for DSM-III-R social and environmental factors, 324 (SCID-P), 42 458 Index

Subjective measures, 55 cross-cultural factors, 248 Substance Abuse and Mental Health Services Hispanic/Latinx diaspora (see Hispanic/Latinx Administration (SAMHSA), 404 diaspora) Substance abuse treatments, 156 posttraumatic symptoms, 247 Substance and Mental Health Services Administration PTSD, 247 (SAMHSA), 283 risk for misdiagnosis, 249 Substance intoxication, 407 survivors, 248, 249 Substance use, 43 treatment and guidelines, 253–254, 258–259, 262 Substance use disorders treatment implications, 262–263 assessment (see Assessment) Trauma- and stressor-related disorders, 422 behavioral treatments, 409 Trauma exposure classification, 407 Asian population, 250–251 cultural factors (see Cultural factors) Black diaspora, 260 factors, 404 Latinx diaspora, 255–256 integrated behavioral health care, 411–413 Trauma-Focused Cognitive-Behavioral Therapy prevalence, 404 (TF-CBT), 426 treatment, 404, 405 Trauma-focused therapy, 426 Substance-induced disorders, 407 Trauma-informed mindfulness-based stress reduction Supernatural impotence, 349 (TI-MBSR), 284 Supported employment programs, 392 Trauma Symptom Inventory (TSI-2), 249 Trauma symptoms African/Blacks, 260–262 T impact of culture, 251–253 Tarvydas Integrative Model, 32 Latinx diaspora, 256–258 Te Vaka model, 157 Treatment Therapeutic alliance, 76, 77 culturally adapted, 408–410 Therapeutic relationship evidence-based therapies, 410 ACT, 88 GAD, 233–235, 241, 242 in CBS and PFM, 86 progress and outcome assessment, 407, 408 for clients, 87 substance use disorders, 404, 405 for clinicians, 87 Treatment credibility, 98, 99, 102, 103, 106 in counseling, 80 Treatment engagement, 118 definition, 76–77 Treatment of sexual dysfunction mechanisms of therapeutic change, 78 cultural modifications, 356 PFM-informed psychosocial treatments, 88 specific disorders, 351 and rapport building, 79 treatment and therapeutic work, 86 DE, 353, 354 Therapeutic techniques ED, 352 behavior therapy, 221 FOD, 354 forgiveness, 223–224 FSIAD, 354, 355 resilience, 225–227 genito-pelvic pain/penetration disorder, 355 self-compassion, 224–225 incorporating traditional medicine, 356 theoretical approaches, 221 MHSDD, 351, 352 therapeutic triad of disability, 222 PE, 353 two-part podcast, 222 plant-based medicine, 356 Therapeutic triad of disability, 222 specific disorders, 351 Therapist–client ethnic matching, 135 Treatment-seeking behaviors, 296 Therapist factors, 76, 77 Thought-action fusion (TAF), 300 Thought disorder, 370 U Timeline followback (TLFB) procedure, 408 UCSD Performance-based Skills Assessment Traditional Hawaiian society, 145 (UPSA), 385 Traditional healing practices, 124 UK’s National Institute for Health and Clinical Translated tests, 66, 67 Excellence (NICE), 284 Trauma Uniform Crime Reporting Program (UCR), 178 African/Black diaspora (see African/Black diaspora) University of Massachusetts (UMass) Medical Asian diaspora, 250 School, 280 Asian populations, 253 Urine analysis, 407 awareness, 248 US-born Hispanic/Latina immigrants, 324 Index 459

V Wellington model, 156 Validity, 54 Wellness/strength based models, 153 Virtue ethics, 29, 33 Worry exposure (WE), 238–239

W Y Wechsler Scales, 54 Yale-Brown Obsessive-Compulsive Scale Weight stigma, 331, 337 (Y-BOCS), 296