cbt culture 200613

Using CBT with South Asian Muslims

Farooq NaeemMBBS, MSc, MRCPsych, PhD

Consultant Psychiatrist & CBT Therapist

Associate Professor, Queens University, Kingston, Canada

Background

Emphasis on culturally adapted psychotherapy for ethnic minorities (USA)

Few guidelines (e.g., Sue, 1990; Bernal, 1995, Hwang, 2006; Tseng 2004; Hays, 2006, Naeem et al, 2009, Rathod et al, 2010)

Few Trials (Hispanics, Latinos, African, Asian)

Status of CBT in Non Western Countries

Cultural competence? Psychotherapy is a cultural phenomenon

Growing diversity of ethnic population

Health disparities between different ethnic groups & Justice or ethical issues (Sue et al, 2009)

Evidence from research (Kohn et al 1999, Sue et al 2005, Naeem et al, 2009)

Developing Culturally adapted CBT, Southampton

Adaptation of CBT in Pakistan

– Depression (2006-9)

– Psychosis

Adaptation of CBT for psychosis in UK (BME population)

Manchester- CA family/ individual therapy for psychosis, substance misuse etc.

Adaptation of CBT for depression in Pakistan

1. Information gathering Interviews with psychologist (Naeem

et al, 2010), Interviews with patients (Naeem et al, in press), Group discussions with students (Naeem et al, 2009) experience of therapy, field observation

1. Southampton adaptation framework (Naeem et al, 2009)

2. Exploratory trial (Naeem et al, 2011)

CBT in non western cultures

English language journals

Few published on depression (Wong et al, 2009, Naeem et al, 2011)

Currently in PakistanRCT of self help,

CBTp- in-patient RCT, brief CBT RCT s (depression and

psychosis), treatment resistant psychosis, CBT for MUS,

One RCT of CBTp in China

Cultural adaptation: Psychosis

Qualitative study to adapt CBTp (Naeem et al, under review)

A total of 92 interviews by 3 psychologists

– Patients (33), Carers (30), Mental health professionals (29) Psychologists (14) Doctors working in psychiatry (15)

exploratory trial of adapted CBT for psychosis (Habib et al, under review)

Bio-Psycho-Social-Spiritual Model Pakistan (Naeem) UK (Shanaya & Peter) UK (Bheeka)

Psycho social stress or worry (25)poverty, (22), loss of balance of mind (2) too much thinking (1) personality (1) Biological hereditary (4), chemicals in brain (6), childbirth (1) phlegm (1) increased heat in liver (1)Spiritual/religious & culturalspirits, magic, taweeds, fear of hawai things (ghosts etc) (8) learning of spiritualism (2) evile eye (1) Gods will (1)Other causes masturbation (1), Don’t know (6)

Previous wrong doingSupernatural beliefs +++++

Social factors ++++

Biological +++

Being arrested Drug induced

Spiritual/religious causes (55%)

Psycho socialStress (18%) Interpersonal causes (20%)

Biological (4.4%).

Dual explanatory models of psychosis (77.7%), combining prescribed medication and seeing a traditional faith healer as a treatment method

Cultural competence in CBT

The Triple A Principle

– Awareness and preparation

– Assessment & engagement

– Adaptation of therapy (minor adjustments)

Awareness and preparation

Southampton Adaptation Framework for SAM (Naeem et al, 2009)

Culture &

related issues

Capacity &

Circumstances

Cognitions &

Beliefs

Cause and effect

Thanks God not Thank you

God’s will not a head injury due to the accident

Language and communication

– Translation of psychological concepts (Name the title technique)

Culture and assertiveness (an example)

North American concept (context)

Based on rights

Asian cultures focus on duties

– Respect (triangulated approach to communication)

– Shame and guilt (Paul Guilberts work)

– Culturally sensitive assertiveness techniques (e.g., apology technique, fogging etc.)

Family related issues

– Both strengths and difficulties

– Help with

Engagement

Follow up

Home work

– Engaging family rather than only patient

Capacity & Circumstances

Individual issues

– Women less likely to seek help

Health system (Resources and organization)

Pathways to care & help seeking behaviour

– Pathways for psychosis different from pathways for depression?

Cognitions & Beliefs

Beliefs about health and illness

– Spiritual/paranormal causes of illness

Beliefs about treatment and treatment provider

– What do you know/think about CBT?

Cognitive errors and dysfunctional beliefs

Assessment

Cultural identity, acculturation & difficulties in cultural adjustments

Understanding of problems/ stigma

Beliefs about illness and its treatment

Expectations from/knowledge of treatment

• Involvement of faith healers, religious healers, alternative healing practices etc.

Engagement-the biggest hurdle

What do patients expect from a (good) healer

Directive style of therapy (Socrates Vs Buddha)

Evidence from research Vs stories of successful cases from other clients

Immediate relief of some symptoms

Therapy- minor adjustments

Psycho education

Family involvement

Culturally accepted treatments

Acceptance/involvement of traditional/faith healers .

Local practices- head massage etc.

Foods/things to avoid- parhaiz

Focus of therapy (e.g., Physical symptoms in thought diaries)

Home work Regular remindersLess of writing workInvolvement of familyUse of beads, audio recorders, mp3 players etc.Time keeping through prayer times Be careful with terminology (e.g., negative

thinking, talking therapy)

Therapy techniques

– Helping clients to identify thoughts & emotions

– Behavioural techniques (Behavioural activation, experiments etc.,) problem solving, etc easy to use.

– Socratic dialogue with care

– Mindfulness/sufisim based techniques with care ? (faith/spiritual authority)

Structural changes in therapy

– Place of therapy, number of sessions, starting therapy while in patient , twice a week sessions initially

Brief vs standard therapy

Use of stories and images

cbt culture 200613

Health & Medicine