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Culturally Sensitive CBT for Refugees: Key Dimensions: Theory, Research and Clinical Practice

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In increasingly multicultural societies, cognitive behavioral therapy (CBT) needs to be made appropriate for diverse groups. Refugees with mental health difficulties present particular therapeutic challenges that include complex trauma, different cultural traditions, and ongoing stress. The current chapter outlines how a contextually sensitive CBT can be developed for such refugee groups. It outlines key dimensions of culturally sensitive CBT, which can be therapeutically implemented among refugees in order to maximize efficacy and effectiveness. These guidelines can be followed to design culturally sensitive CBT studies among refugees, or what might be called “contextually sensitive CBT,” and the guidelines can be used to evaluate such studies. Some examples of these key dimensions of care are the following: assessing and addressing key local complaints (e.g., somatic symptoms, spirit possession, and syndromes like “thinking a lot”); incorporating into treatment key local sources of recovery and resilience (e.g., CBT-compatible proverbs and techniques in that culture). Another example of a key dimension of care is making CBT techniques more tolerable and effective for the cultural group through various means: by using a phased approach, by utilizing culturally appropriate framing of CBT techniques (using local analogies), by making positive re-associations to problematic sensations during interoceptive exposure (e.g., to traditional games), and by using trauma-type exposure as an opportunity to practice emotion regulation. We describe such concepts as explanatory model bridging, cultural grounding, and contextual sensitivity.
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201© Springer Nature Switzerland AG 2018
N. Morina, A. Nickerson (eds.), Mental Health of Refugee and Conict-Affected
Populations, https://doi.org/10.1007/978-3-319-97046-2_10
Culturally Sensitive CBT forRefugees:
Key Dimensions
DevonE.Hinton andAnushkaPatel
Abstract In increasingly multicultural societies, cognitive behavioral therapy
(CBT) needs to be made appropriate for diverse groups. Refugees with mental
health difculties present particular therapeutic challenges that include complex
trauma, different cultural traditions, and ongoing stress. The current chapter out-
lines how a contextually sensitive CBT can be developed for such refugee groups. It
outlines key dimensions of culturally sensitive CBT, which can be therapeutically
implemented among refugees in order to maximize efcacy and effectiveness.
These guidelines can be followed to design culturally sensitive CBT studies among
refugees, or what might be called “contextually sensitive CBT,” and the guidelines
can be used to evaluate such studies. Some examples of these key dimensions of
care are the following: assessing and addressing key local complaints (e.g., somatic
symptoms, spirit possession, and syndromes like “thinking a lot”); incorporating
into treatment key local sources of recovery and resilience (e.g., CBT-compatible
proverbs and techniques in that culture). Another example of a key dimension of
care is making CBT techniques more tolerable and effective for the cultural group
through various means: by using a phased approach, by utilizing culturally appro-
priate framing of CBT techniques (using local analogies), by making positive re-
associations to problematic sensations during interoceptive exposure (e.g., to
traditional games), and by using trauma-type exposure as an opportunity to practice
emotion regulation. We describe such concepts as explanatory model bridging, cul-
tural grounding, and contextual sensitivity.
Keywords Culture · CBT · Trauma · Refugees
D. E. Hinton (*)
Harvard University, Boston, MA, USA
e-mail: devon_hinton@hms.harvard.edu
A. Patel
Department of Psychology, University of Tulsa, Tulsa, OK, USA
e-mail: anushka-patel@utulsa.edu
202
Psychological interventions that are effective across cultural groups are needed, with
refugees being a case in point. There is a global refugee crisis with over 65.3 million
people estimated to be forcibly displaced from their home countries (United Nations
High Commissioner for Refugees, 2016). Refugees with mental health complaints
are complex to treat for many reasons. As one challenge, ongoing stresses interact
with complex trauma to make treatment more difcult. Refugees face several unique
stressors in the course of the pre-displacement, displacement/resettlement, and post-
migration context. For instance, refugees experience higher rates of trauma exposure
compared to the general population (Porter & Haslam, 2005), as they are often sub-
jected to and/or witness human rights violations during the conicts from which
they seek political asylum. The types of traumatic events experienced by refugees
include starvation, loss of a loved one, physical violence, rape, torture, and brain-
washing (Mollica etal., 1992). Refugees also experience loss on many levels; being
exiled from their homelands, refugees lose material possessions of personal and
cultural signicance, in addition to social support networks, and connections with
cultural traditions. These various risk factors predispose refugees to having post-
traumatic stress disorder (PTSD) and other mental illnesses (Morina & Ford, 2008).
As another challenge in treating refugees, owing to having differing cultural tra-
ditions, there may be certain key presentations of distress, psychopathological pro-
cesses, and local symptom meanings and healing traditions (Hinton & Good, 2009,
2016a; Kleinman & Good, 1985). For example, PTSD differs greatly across cul-
tures with respect to the constellation of symptoms that emerge and their meaning
(Hinton & Good, 2016b), as does panic disorder (Hinton & Good, 2009) and depres-
sion (Kleinman & Good, 1985).
Evidence demonstrates that cognitive-behavior therapy (CBT) is effective for a
wide range of disorders including PTSD (Hofmann & Smits, 2008). However, most
research on CBT has focused on Western populations, and research is just beginning
to examine whether CBT is effective for ethnic minority and refugee groups and in
global contexts and how it should be adapted (e.g., Bass etal., 2013; Drozdek,
Kamperman, Tol, Knipscheer, & Kleber, 2014; Hinton, 2014; Hinton, Pich,
Hofmann, & Otto, 2013; Murray et al., 2014; Naeem, Waheed, Gobbi, Ayub, &
Kingdon, 2011; Nickerson, Bryant, Silove, & Steel, 2011). A systematic review of
ten randomized controlled trials (RCTs) evaluating treatments for refugees with
mental health problems found some promise in CBT, and argued that there is a need
to adapt treatments to the local cultural context (Crumlish & O’Rourke, 2010).
How can CBT treatments be culturally adapted? Bernal and colleagues dene cul-
tural adaptation as the “systematic modication of an evidence-based treatment (EBT)
to account for language, culture, and context in a way that is consistent with the cli-
ent’s cultural patterns, meanings and values” (Bernal, Jiménez-Chafey, & Domenech
Rodríguez, 2009, p.362). Griner and Smith (2006) reviewed 76 studies on culturally
adapted mental health interventions for a wide range of disorders, and they found that
interventions targeted to specic ethnic groups produced four times stronger effects
than those provided to diverse ethnic groups. Benish, Quintana, and Wampold (2011)
also found that culturally adapted treatment is more effective than un-adapted treat-
ment (d=.32) in a direct-comparison meta-analysis. The only signicant moderator
D. E. Hinton and A. Patel
203
accounting for this difference was modication of the explanatory model. This study
highlights the importance of eliciting a group’s explanatory model– that is, the way in
which a group understands an illness experience, including ideas about causation, key
symptoms, and cures– and adapting treatment in accordance with it. As this and many
other studies show, understanding the client’s interpretation of symptoms and provid-
ing treatment congruent with their explanatory model is a key ingredient in culturally
adapted treatment (for further discussion of explanatory model, see Hinton, Lewis-
Fernández, Kirmayer, & Weiss, 2016). Of note, this may entail changing the patient’s
explanatory model of the origins of the disorder: For a Western patient who has a
purely biological model and expects only medication, creating illness models under-
standable to the patient as to why psychotherapy may work for panic disorder, or for a
Cambodian patient who attributes panic symptoms to a khyâl attack, so too why psy-
chotherapy may be effective. We refer to these various processes of working with the
patient’s explanatory model to further treatment as explanatory model bridging.
The present chapter aims to integrate knowledge of clinical science with cultural
competence to present key considerations for adapting CBT across cultural settings.
Specically, this chapter provides recommendations on how to make the next wave
of CBT treatments for refugees more culturally sensitive. We suggest parameters that
can be used to develop culturally sensitive CBT interventions among refugees or
other cultural groups in a given global location in what might be called “contextually
sensitive CBT.” Many of these parameters have guided our treatment development,
and the global health research agenda more generally (Hinton etal., 2005; Hinton,
Hofmann, Pollack, & Otto, 2009; Hinton, Hofmann, Rivera, Otto, & Pollack, 2011;
Hinton etal., 2004; Hinton, Rivera, Hofmann, Barlow, & Otto, 2012; Patel, 2012;
van Ginneken etal., 2013). Each dimension, and its constituent parts, is summarized
in Table1 and discussed below. These dimensions serve a twofold purpose: They can
be addressed to attain contextual sensitivity in a treatment that is being developed,
and also be used to evaluate the contextual sensitivity of extant treatments.
Key Dimensions ofCulturally Sensitive CBT
Background Information
Identify the Cultural Group The exact cultural group needs to be specied, not just
that the participants are from a certain broad group or a certain country. As an
example, Latinos may be Caribbean Latino, Central American, South American, or
Mexican, and each of these groups has a unique social and cultural history; or yet
still, those treated may be members of a minority groups within the country, such as
Quechua speakers in Peru.
Specify the Language of the Group and Language of Treatment The language the
participants speak should be specied. It should be noted whether the treatment
was conducted in the preferred or a secondary language, and whether an interpreter
Culturally Sensitive CBT forRefugees: Key Dimensions
204
was used. In many countries there are multiple languages spoken but a single
national language, with variable uency in the national language. For example, in
Iraq, while Arabic is the national language, Arabic is not spoken in major parts of
Northern Iraq, where Kurdish and Turkmen are the dominant languages.
Table 1 Dimensions of culturally sensitive CBT
Therapeutic dimensions Subdimensions
Assess relevant background
information
The exact cultural group
The language of the group and language of treatment
Key demographic variables
Religious background of the group
Address key stressors and traumas Key stressors
Typical traumatic events in the group
Identify and address key local
symptom and syndrome concerns
Complaints of most concern to those being treated:
Somatic complaints and local illness categories and related
catastrophic cognitions
Complaints and behaviors of most concern to the
community: Substance abuse, suicidality, violence
Address DSM disorders dimensions
of psychopathology
Key DSM disorders
Key psychopathological dimensions (e.g., worry, panic,
and catastrophic cognitions)
Create universal and local models
of how key complaints are
generated
Universal model of how disorder is generated
Local model of how disorder is generated
Utilize local sources of resilience
and recovery
Proverbs, ethnopsychology, and religious practices (e.g.,
Dhikr or meditation) that promote resilience and recovery
Maximize credibility and positive
expectancy
Take into consideration the local ethnopsychology,
ethnophysiology, and ethnospirituality (e.g., address
related catastrophic cognitions)
Frame the treatment as addressing the problems of most
concern
Utilize local metaphors and proverbs and refer to local
practices that teach CBT principles
Testimonials by those who have recovered and by
community leaders
Make CBT techniques more
tolerable and effective for the
cultural group
A phased approach when doing exposure
Re-association to positive imagery during interoceptive
exposure
Exposure as an opportunity to teach emotion regulation
techniques
Culturally appropriate analogies and metaphors
Maximize access Address stigma about the disorder and getting treatment
for the disorder
Address structural barriers to treatment
Maximize adherence
Specify scale-up and sustainability potential
D. E. Hinton and A. Patel
205
Identify Key Demographic Variables The treatment population should be charac-
terized in terms of key demographic variables such as gender, socio-economic sta-
tus (SES), education, and literacy level. The level of education and literacy will
determine whether written handouts can be used and may indicate whether use of
technology (e.g., CDs containing therapeutic materials) can be a feasible treatment
component or whether one must use easy-to-understand diagrams and gures.
Furthermore, variables like SES may indicate current levels of stress, which may
inuence the ability to tolerate and benet from therapy. For instance, exposure
therapy may be contraindicated in groups experiencing a high degree of ongoing
stress (Lester, Resick, Young-Xu, & Artz, 2010).
Detail the Religious Background of the Group and Its Impact on Treatment It
should be determined whether the participants are members of a certain religion,
such as Buddhism, Christianity, or Islam, and moreover, which denomination of
that religion: Therevadan or Zen Buddhism, Pentecostal or Catholic Christianity, or
Sunni or Shia Islam. The clinician should also determine the patient’s attitude to that
tradition: devout, agnostic, or hostile. Religious hybridity should also be taken into
account; for example, Christianity among the Sepedi tribe of South Africa is an
amalgamation of traditional Christianity and local beliefs in ancestral spirits, evil
curses, and black magic. Religion may inuence explanatory models of illness, and
key aspects of the group’s viewpoints of illness may be missed if religious identity
has not been duly assessed. Ideally local religious leaders should rst be consulted
to determine their understanding of the types of distress in the population, what
religious and other treatments they think should be implemented, and how they
think Western-type interventions might be successfully conducted. Religious or
spiritual traditions may provide sources of resilience or constitute obstacles to care.
Incorporating sources of resilience from the religious traditions themselves and
anticipating potential objections from the religious communities may improve the
acceptability and efcacy of treatment in such settings: For example, in some
Islamic cultures, it may be necessary to match therapist and client in respect to gen-
der as a way of adapting treatment to religious beliefs (Murray etal., 2014).
Assess andAddress Local Stressors andTraumas
Worry and current life concerns are a key generator of distress, particularly in trau-
matized populations (Hinton & Lewis-Fernández, 2011; Hinton, Nickerson, &
Bryant, 2011). From a public health standpoint, when applying CBT in global con-
texts, it is important to be aware of local problems that may be addressed for the
entire group: examples include security concerns, refugee status, and access to clean
water (Bolton, Michalopoulos, Ahmed, Murray, & Bass, 2013; Hinton & Hinton,
2015). Ideally such concerns may be addressed at the community level as a public
health intervention. Additionally, it should be specied whether the participant in
CBT has an advocate, such as the equivalent of a social worker, who can help
Culturally Sensitive CBT forRefugees: Key Dimensions
206
address key practical problems. As such, CBT may need to address practical prob-
lems as part of treatment, which also serves as a way to increase behavioral activa-
tion and improve participants’ coping skills (Nezu, Nezu, & Lombardo, 2004).
In addition to ongoing stressors, past and current traumas common in the group
should be clearly identied and the effects researched. The group in question may
have endured mass violence of some kind. Prior to commencing CBT with a client,
the client should be screened for current traumas (e.g., ongoing domestic violence),
and if detected provided with resources that can facilitate coping. Ongoing trauma
may include sexual and/or domestic violence, which is especially common in
groups where gender disadvantage is culturally sanctioned (Patel, Kirkwood,
Pednekar, Weiss, & Mabey, 2006).
Identify andAddress Key Local Symptom andCultural
Syndrome Concerns
Identify and Address Distress Complaints of Most Concern to those Being
Treated Failure to assess and treat key concerns such as somatic symptoms, posses-
sion, and cultural syndromes is to commit “category truncation,” resulting in a lack
of content validity (Hinton & Good, 2016b). In a particular cultural context, certain
symptoms may be of great concern. For instance, among many Cambodian refu-
gees, sleep paralysis, dizziness, poor sleep, and panic attacks warrant high levels of
distress (Hinton, Kredlow, Pich, Bui, & Hofmann, 2013). The key local complaints
may also manifest as cultural syndromes. For example, Cambodians frequently
attribute anxiety symptoms to “heart weakness” and “wind attacks” (khyâl attacks),
that is, a dangerous surge of khyâl and blood upward in the body (see below), and
these attributions produce multiple catastrophic cognitions. Similarly, possession
fears are prevalent in traumatized populations in certain African contexts, with
PTSD and arousal symptoms sometimes being attributed to possession (de Jong &
Reis, 2010, 2013). These complaints are experience-near categories; that is, they are
the very terms that are used by members of the group to describe distress, and are
therefore highly related to self-perceived well-being. The experience-near catego-
ries, according to which disorder is locally understood, are usually not Diagnostic
and Statistical Manual of Mental Disorders (DSM) categories but other local cate-
gories such as khyâl attacks among Cambodian populations and “thinking a lot”
among many cultural groups (Bolton, Surkan, Gray, & Desmousseaux, 2012; Kaiser
etal., 2014; Patel, Simunyu, & Gwanzura, 1995; Yarris, 2014).
Ideally outcome studies in cross-cultural settings should include a list of locally
salient complaints, particularly somatic complaints, and a list of cultural syndromes.
These lists are referred to as a “Symptom and Syndrome Addendum”, for example, a
“Cambodian Symptom and Syndrome Addendum,” or C-SSA (Hinton, Hinton, Eng,
& Choung, 2012; Hinton, Kredlow, et al., 2013). Certain locally salient complaints
may be particularly important to assess across treatment: For example, in the
D. E. Hinton and A. Patel
207
Cambodian refugee groups, orthostatic dizziness (Hinton etal., 2009; Hinton, Hinton,
etal., 2012; Hinton, Hofmann, et al., 2011; Hinton, Kredlow, etal., 2013), and in
some Latino groups, ataques de nervios (Hinton, Hofmann, etal., 2011), which con-
sists of the sense of a dangerous disorder of the “nerves” that may cause loss of
control and various bodily disasters (e.g., uncontrollable shaking and asphyxia).
Framing treatment as addressing these key complaints greatly increases CBT
acceptability and adherence, and helps to identify and address catastrophic cogni-
tions. As a therapeutic intervention, the client can be told that the culturally salient
items in the assessment battery should improve during treatment. This accomplishes
many goals, such as addressing distress in terms of local explanatory models and
symptoms of concern, alleviating catastrophic cognitions, and increasing positive
expectancy (Benish etal., 2011; Hinton, Lewis-Fernández, etal., 2016).
Identify and Address Symptom and Syndrome Complaints of Most Concern to the
Community One should ask local leaders, if present, about their key concerns relat-
ing to those in the community with psychological distress; for example, they may
mention substance abuse or suicidality. Framing the treatment as addressing these
issues may mobilize local leaders and the community to engage community mem-
bers in treatment. Local leaders may include political, religious, and informal and
formal health providers, as well as heads of local advocacy groups who have earned
respect in the community. The aim of engaging such leaders is to have the commu-
nity focus more on resolution rather than on blaming the victim or using other forms
of non-productive labeling. It provides an alternative framing by contextualizing
behaviors as resulting from social and psychological distress.
Address DSM Disorders andDimensions ofPsychopathology
Identify and Address Key DSM Disorders In some groups, such as traumatized
refugees, certain disorders like PTSD and panic disorder may be particularly ele-
vated owing to complex trauma, ongoing stressors, and catastrophic thought pat-
terns about symptoms (Hinton & Lewis-Fernández, 2011). For example, Cambodian
refugees not only experience PTSD but also have extremely high rates of panic
attacks and panic disorder. If panic attacks are common in a locality, this will inu-
ence assessment and the recommended treatment modules. As such, each group
may have a unique prole of DSM disorders. The prole of disorders will inform
treatment and the design and implementation of modules.
Identify and Address Key Psychopathological Dimensions Other than DSM disor-
ders, it is important to identify key psychopathological dimensions in a group, such as
pathological worry, catastrophic cognitions, somatic symptoms, panic attacks, anger,
substance abuse, or suicidality (Hinton, Nickerson, etal., 2011; Morris & Cuthbert,
2012); This analytic approach is consistent with the call to use dimensional analysis
to identify treatment targets (Casey etal., 2013). Knowledge of these dimensions can
Culturally Sensitive CBT forRefugees: Key Dimensions
208
inform treatment more specically than simply focusing on DSM-5 symptoms, and
can result in tailored culturally adapted care. Failing to address key distress dimen-
sions among distressed traumatized populations in cross-cultural settings is an exam-
ple of category truncation, which may lead to poor care (Hinton & Good, 2016a).
As an example of a key dimension to assess and track among traumatized refu-
gee groups, it has been found that somatic symptoms form a prominent aspect of the
illness experience in many non-Western populations (de Jong, Komproe, Spinazzola,
van der Kolk, & van Ommeren, 2005; Hinton & Good, 2009; Hinton & Lewis-
Fernández, 2011). Ideally one should identify key somatic concerns in a population
so that these may be addressed in CBT; this can be considered as the assessment of
a psychopathological dimension.
Another key psychopathology dimension relevant to the adaptation of CBT is
catastrophic cognitions. A standard part of CBT is addressing catastrophic cogni-
tions about symptoms, such as those concerning PTSD and somatic symptoms
(Hinton, Rivera, etal., 2012). Learning the local ethnopsychology, ethnophysiol-
ogy, and ethnospirituality as it applies to symptoms and processes like “worry” is a
key way of identifying these catastrophic cognitions. In every culture, there will be
local ideas about how symptoms of anxiety and depression are generated and
treated. For example, many Cambodian refugees fear that neck soreness indicates
the neck vessels will burst. Similarly, they hold that dizziness on standing indicates
the onset of a dangerous khyâl attack, or “wind attack,” in which a surge of khyâl
and blood upward in the body is believed to cause various symptoms and disasters
such as asphyxia by compressing the lungs, heart arrest by pressing on the heart,
bursting of the neck vessels by dilating vessels, and fatal syncope by inltrating the
cranium (Hinton & Good, 2016a; Hinton, Pich, Marques, Nickerson, & Pollack,
2010). Cambodian refugees also tend to be concerned that worry will overheat the
brain and cause permanent forgetfulness, and that palpitations will cause heart
arrest. Among the Sepedi tribe of Northern Sotho, it has been found that PTSD
symptoms and somatic symptoms give rise to fears of possession and attack by
spirits (on possession fears elsewhere in Africa, see de Jong & Reis, 2010, 2013).
The clinician can address catastrophic cognitions by giving an alternative framing
in terms of the biology of anxiety, by teaching clients to control the symptom by
relaxation methods (breath-focused techniques or applied stretching and muscle
relaxation), and by interoceptive exposure1 that teaches the innocuousness of these
symptoms.2
1 Interoceptive exposure is a cognitive behavioural therapy technique used in the treatment of panic
disorder in which the individual is exposed to interoceptive sensations like dizziness to decrease
fear of them.
2 In many Buddhist countries symptoms may be attributed to bad spiritual status. If the client thinks
the current state is due to “low merit” or past bad actions (“bad karma”), the client can be encour-
aged to use cultural means to elevate spiritual status. As such, meditating or projecting loving
kindness are considered merit-making and by doing these activities, the client regains a sense of
agency (there is a transformation of self-image). Thus, the client engages in a practice that is thera-
peutic by both local and “scientic” standards. Note that addressing concerns about a depleted or
D. E. Hinton and A. Patel
209
Create Universal andLocal Models ofHow Key Complaints Are
Generated inthePopulation inQuestion inOrder toIdentify
Treatment Targets andModes ofIntervention
How particular key complaints come to be generated should be identied in terms of
two types of causal network models (McNally, 2012): universal and local models.
Construct Universal Models One should create universal models of how the com-
plaint is generated. We have used multiplex models (Fig.1) to show how key com-
plaints are generated among Cambodian refugees with trauma-related symptoms.
These causal models identify treatment targets, such as triggers of distress, and the
nature of catastrophic cognitions, and provide a model of the generation of distress
that can be shared with the client (Benish etal., 2011; Hinton & Lewis-Fernández,
2010). For example, we have used such models to explain why Cambodian refugees
have high rates of somatic complaints and panic attacks and how they are generated.
Among Cambodian refugees, we have determined that panic attacks often began
with a somatic symptom that is caused by a trigger, such as worry or by standing up
from a sitting or lying position. Next, the triggered somatic symptom may give rise
to catastrophic cognitions, for example, worry-caused dizziness resulting in fears of
the onset of a dangerous khyâl attack; and the triggered somatic symptom may
evoke trauma associations, for example, worry-caused dizziness bringing about
memories of doing slave labor while starving (Hinton etal., 2010; Hinton & Good,
2009; Hinton, Hofmann, Pitman, Pollack, & Barlow, 2008; Hinton, Nickerson,
etal., 2011). The model takes into account local ideas about the workings of the
body by emphasizing the assessment of catastrophic cognitions.
inauspicious spiritual status is often part of addressing catastrophic cognitions because the percep-
tion of low spiritual power and thus great vulnerability leads to multiple types of catastrophic
cognitions: that spirit attack may lead to sleep paralysis and that somatic symptoms are due to
invasion by a spirit.
Mental or somatic symptom
Trauma associations to the symptom
Catastrophic cognitions about the symptom
(e.g., owing to local cultural syndromes
involving the symptom)
Escalating distress and arousal
Trigger of
mental or somatic symptom
Fig. 1 A multiplex model of the generation of trauma-related distress
Culturally Sensitive CBT forRefugees: Key Dimensions
210
Determine Local Models How key symptoms are generated according to the local
ethnopsychology should also be determined, which often involves local cultural syn-
dromes; this reveals the local explanatory models. These local models of mental
distress highlight multiple possible treatment targets and support the discussion of
symptoms and interventions in a way that will be locally understood. Determining
local models allows the clinician/researcher to ground the treatment in the local con-
text and to create a bridge from current psychological theory to local explanatory
models. To give an example, one type of syndrome found in many cultures, “thinking
a lot,” can be investigated (Hinton etal., 2008; Hinton, Reis, & de Jong, 2015, 2016),
providing an important entrée to local ethnopsychology and ethnophysiology. (On
“thinking a lot,” see also Bolton etal., 2012; Kaiser etal., 2014; Patel etal., 1995;
Yarris, 2014.) Figure2 shows how the syndrome of “thinking too much” is concep-
tualised among Cambodian refugees. According to the Cambodian conceptualiza-
tion, there is the trigger of an episode, which is often worry, but also may be thoughts
about past traumas, rumination over past failures, or pained recall of someone who
has died or lives far away; then this “thinking too much” may cause poor sleep and
weakness, which in turn causes more “thinking too much.” Furthermore, according
to the Cambodian conceptualization, “thinking too much” may cause anger and vari-
ous serious disturbances of mind and body, such as permanent forgetfulness and
khyâl attacks”. Figure2 also shows how Cambodians traditionally treat “thinking a
lot.” Because of the commonality of “thinking a lot” across the globe, and its central-
ity in psychopathology, its evaluation is a key way of investigating local ideas about
mental disorder. As such, we have proposed a questionnaire that can be used to con-
duct an assessment of “thinking a lot” in any cultural group (Hinton etal., 2015).
"Thinking too much"
(about current worries,
trauma events,
depressive themes,
bereavement issues)
Anger and irritability Toxique
(dangerous to
self and others
owing to extreme
irritablity)
Crazy (
attacks
(caused by a disruption of
in the body)
Many symptoms (dizziness, shortness of
breath, neck soreness) and possibly
death from bodily dysfunction (syncope,
asphyxia, neck rupture)
Treating "thinking too much" and its induced symptoms
(e.g., by attentional control, meditation, mindfulness, obeisance to the Buddha, "coining," snapping the joints, and taking
tonics and sleep and appetite promoters)
(pluc pleang)
Poor sleep
and
appetite
Weakness
Overheated brain
Fig. 2 The cambodian explanatory model of “thinking too much” and its treatment
D. E. Hinton and A. Patel
211
Utilize Local Sources ofResilience andRecovery
A key part of local resilience and recovery may be the local proverbs, ethnopsychol-
ogy, and religious tradition. Incorporating such proverbs, teachings, and practices
into CBT can increase cultural acceptability and positive expectancy related to the
treatment. Useful proverbs may have religious origins. For instance, Rumi, a famous
Persian poet, presented a proverb that helps to teach the virtue of gratitude: “Wear
gratitude like a cloak and it will feed every corner of your life”. In certain localities,
there may be healing traditions such as Buddhist practices or Islamic spirituality
(e.g., Tazkiyah-tul-nafs, or “purication of the soul”) that are helpful to clients
(Hinton & Kirmayer, 2013). These techniques can inform the application of CBT
treatment itself, and participants may then be encouraged to use such methods. For
Buddhists, incorporating meditation into the treatment may be useful. For some
Islamic populations, incorporating a type of supplication known as Dhikr where
God is repeatedly praised using various honoric names, may also be warranted. In
our treatment for traumatized Southeast Asian refugees, we utilize multiple mind-
fulness techniques to improve the skills of clients in coping with anxiety (Hinton,
Ojserkis, Jalal, Peou, & Hofmann, 2013; Hinton, Pich, etal., 2013).
In some cases, it is useful to end the CBT treatment with local rituals that indi-
cate purication or healing in a general sense, which helps to change self-image and
to create a sense of positive expectancy (Hinton, Rivera, etal., 2012). Such rituals
help to improve one’s self-imagery, which is a key issue in traumatized and other
populations. These rituals create the sense of being transformed and thereby increase
positive expectancy (Agger, Igreja, Kiehle, & Polatin, 2012; Hinton, Rivera, etal.,
2012). For example, Wudhu and Ghusl (ritualistic washing of face, arms, and feet)
for an Islamic population are types of spiritual purication techniques signifying a
transition from spiritual impurity to purity (Amer & Jalal, 2011; Haque, 2004);
among Southeast Asian populations, transition is often marked by various types of
steaming rituals.
Maximize Credibility andPositive Expectancy
Increasing credibility and positive expectancy regarding treatment has various
effects such as enhancing adherence and efcacy (Benish etal., 2011; Gone, 2013;
Rutherford & Roose, 2013; Tsai, Ogrodniczuk, Sochting, & Mirmiran, 2014).
Credibility and expectancy can be increased in the following ways.
Take into Consideration the Local Ethnopsychology, Ethnophysiology, and
Ethnospirituality Credibility and positive expectancy will be increased by eliciting
the client’s explanatory model of disorder, explaining how that model relates to the
Culturally Sensitive CBT forRefugees: Key Dimensions
212
proposed CBT treatment, and addressing concerns related to the client’s explana-
tory model such as key complaints and catastrophic cognitions (Hinton, Lewis-
Fernández, etal., 2016; Hinton, Rivera, etal., 2012; Ventevogel, Jordans, Reis, & de
Jong, 2013). Giving explanations of the intervention that are culturally consonant
might be called “explanatory model bridging” (Fig. 3).3 Credibility and positive
expectancy may be enhanced by referring to local therapeutic techniques in treat-
ment, such as meditation in a Buddhist context, and, Dhikr or Ruqyah in Islamic
contexts. Such techniques may also be used in the treatment when appropriate.
Frame the Treatment in Terms of the Problems of Most Concern It should be
explained how the treatment will help with complaints of greatest concern, such as
key symptoms like dizziness and sleep paralysis and key cultural syndromes like
“weak heart” and “thinking a lot.” For example, in our CBT treatments, we speci-
cally mention that the treatment will relieve the complaints in the Symptom and
Syndrome Addendum.
Use Local Metaphors and Proverbs and Refer to Local Practices Consonance
between clinician and client explanatory models is a central mechanism of change
3 The attempt at bridging, which requires eliciting the client’s explanatory model, is seemingly
efcacious for various reasons: increasing positive expectancy and credibility by increasing the
client’s feeling that the therapist’s understands their concerns and by identifying catastrophic cog-
nitions about symptoms (Hinton, Lewis-Fernández, etal., 2016). A recent review indicated that
cultural adaptation of treatment increased effect size, and that the key aspect of cultural adaptation
was eliciting the client’s explanatory model of disorder (Benish etal., 2011).
The patient's explanatory model
of his or her problem
The clinician's explanatory
model of the patient's problem
The patient's explanatory model of the
treatment offered by the clinician
Explanatory Model Bridging
Clinician
Patient
The clinician's explanatory model of
the treatment offered to the patient
Fig. 3 The core clinical task of explanatory model bridging, with the clinical encounter cong-
ured as the negotiation of four types of explanatory models
D. E. Hinton and A. Patel
213
in therapy. The use of local metaphors, proverbs, and practices is another example
of explanatory model bridging; that is, creating a bridge between the clinician’s and
client’s view of disorder. This is part of the cultural grounding of CBT, which
increases credibility and positive expectancy, in addition to aiding a client in retain-
ing information. For example, at the beginning of treatment we compare our CBT
to the making of a special local dish that involves multiple culinary steps to promote
positive expectancy and teach patience regarding timeframe of their improvement.
When doing interoceptive exposure, we re-associate the induced sensations such as
dizziness in head rolling to local games and practices that induce that same sensa-
tion. Similarly, we re-associate these types of sensations with more positive imagery
germane to clients, for example, from the Islamic tradition, by introducing the holy
image of whirling dervishes.
Metaphors, analogies, and proverbs may also be taken from the religious tradi-
tion to teach about emotion regulation such as anger control. In Cambodian
Buddhism, for example, anger is compared to a dangerous re; the proverb,
“Controlling getting angry once results in a gain of a hundred days of happiness”
(Nickerson & Hinton, 2011) may also be relevant to treatment. Likewise, anger is
highly discouraged in the Islamic tradition. It is narrated that the Prophet of Islam,
Muhammad, advised, “The strong man is not the one who can throw another down.
The strong man is the one who can keep hold of himself when he is angry.
Muhammad also stated that “Anger is from Satan, and Satan was created from re.
Fire is extinguished by water, so if one of you gets angry, he/she should perform
Wudhu” (ritualistic washing of face, arms, and feet to cool down) (Amer & Jalal,
2011; Haque, 2004).
Utilize Testimonials by Community Leaders and Those Who Have
Recovered Showing videos of local leaders who advocate treatment and attest to its
efcacy may help improve credibility and positive expectancy, as may testimonial
videos of those who have gotten better through the treatment (if permissions are
obtained and it is culturally appropriate).
Make CBT Techniques Tolerable fortheCultural Group
To increase tolerability of interoceptive exposure, in our treatment we frame the
techniques as a “game” and try to create positive associations to somatic sensations
that are germane in that context. During head rolling exercises, the clinician can
evoke the joy experienced by a child while rolling down a hill. It has been found that
conducting exposure to trauma memories among ethnic populations presents chal-
lenges and may lead to drop out and worsening of symptoms (Hinton, 2012). With
Western populations too, exposure conducted even by doctoral level therapists, has
been problematic. However, narrative exposure therapy uses traditional exposure—
with minimal preparation or modication— and has been shown to be effective in
several countries (Morkved etal., 2014). Metaphors used to frame techniques may
Culturally Sensitive CBT forRefugees: Key Dimensions
214
promote credibility and tolerability (Hinton, Rivera, etal., 2012; Hwang, 2006) and
exposure may be facilitated by references to local practices. For example, one
research group compared imaginal exposure to cleaning a wound (Murray etal.,
2014). In another instance, the comparison equated the fear of exposure to the fear
local women initially have of making bread on an open re, as it is a fear that typi-
cally diminishes over time (Murray etal., 2014). In our treatment for Cambodian
refugees, to increase tolerability and efcacy of exposure, we use the distress result-
ing from exposure as an opportunity to teach emotion regulation techniques (Hinton,
Rivera, etal., 2012); for instance, by teaching loving kindness and mindfulness and
providing self-metaphors of exibility subsequent to exposure.
Maximize Access
Address Stigma About the Disorder and Getting Treatment for the Disorder One
should determine how various psychological disorders and associated symptoms
are locally viewed. The psychological disorders and associated symptoms should be
normalized with the goal of reducing self-stigma and stigmatization by others.
Family members may need to be educated about the illness. Videos of community
leaders and possibly clients (if permissions are obtained and it is culturally appro-
priate) in which they talk about the disorder and the importance of treatment may be
useful. Treatment can be framed as addressing locally salient concerns that are not
stigmatizing, such as poor sleep, nightmares, or somatic complaints. If coming to
the location of treatment remains stigmatizing, it may be necessary to provide treat-
ment in a primary care or another non-stigmatizing locality.4
Address Structural Barriers to Treatment Structural barriers to treatment include
transportation issues, difculty paying for health care, and problems taking time off
to go to the clinic. Transportation issues and time constraints may be alleviated by
providing services in primary care. However, payment issues may well require gov-
ernmental level shifts in policy.
Maximize Adherence Adherence includes attending sessions and trying to imple-
ment the treatment in daily life. Adherence will be increased by anything that
decreases stigma, helps to increase credibility and positive expectancy, increases
tolerability, or addresses structural barriers. So, for example, adherence will be
increased by using metaphors that emphasize the need to complete all parts of the
4 In respect to trauma, one may need to address social blaming and self-blaming: a rape victim may
be blamed and stigmatized. In many Asian countries, the concept of karma (i.e., the idea that what
happens to one is a result of past bad actions and so is deserved) can lead to a blaming of the vic-
tim. It should be noted that local models like that of karma may be used as a justicatory frame for
perpetration of violence and need to be addressed at the community level. More generally, stigma-
tization of the survivor may need to be addressed at various levels such as through nding group
consensus and utilizing local religious and transnational human-rights frames.
D. E. Hinton and A. Patel
215
treatment, like the metaphor in which all elements of the treatment are analogized
to the steps needed to prepare a dish that is highly prized in the culture.
Specify Scale-Up and Sustainability Potential Scale-up and sustainability will be
greatly inuenced by the level of education required of the service provider, how
much time is needed to be trained in treatment provision, whether the treatment can
be taught to multiple providers, how many sessions the treatment entails, whether
the treatment is in a group or individual format, and the extent to which treatment
can be delivered by non-specialists via task shifting (Chisholm etal., 2007; Patel,
2012). The scale-up and sustainability potential will be inuenced by public health
system variables as well. Examples of such factors include whether there is a place
in the health care system to situate the treatment, whether the government is willing
to incorporate the CBT into standard treatment, and whether funding is available for
the program (Jordans & Tol, 2013). Therefore, keeping records of nancial and
labor costs can help to ascertain initial feasibility of such treatments.
Conclusion
In this chapter we have outlined some key ways of developing and implementing CBT
in global contexts in a culturally sensitive way that maximizes efcacy and effective-
ness. In studies involving CBT, the guidelines outlined (see Table1) can be used as a
checklist of cultural sensitivity, to support the development and implementation of
contextually sensitive CBT.Ideally, preliminary research will be done to obtain the
information shown in Table1 prior to initiating CBT.The type of information speci-
ed in Table1 can be gathered in various ways.
As an initial way to obtain the information in Table1, there should be a review of
the literature, discussion with community leaders, ethnographic surveys, and pilot
treatment studies. As we have suggested, in designing a treatment, a good initial
starting point is the determination of common presenting key complaints in a com-
munity. Then one can investigate the relationship of the complaint to DSM disorders
and to dimensions of pathology, and one can evaluate local ideas about the com-
plaint’s cause, local ideas about the how the complaint arises from disturbance in the
psychological, physiological, and spiritual state, and local ideas about how the com-
plaint can be best treated. To facilitate evaluation of the complaint, the explanatory
model from the cultural formulation can be used (Hinton, Lewis- Fernández, etal.,
2016). In localities where “thinking a lot” is common, using the “thinking a lot”
questionnaire (Hinton etal., 2015; Hinton, Reis, etal., 2016) is a good way to learn
about the local ethnopsychology and ethnophysiology and about current stressors.
The questionnaire can also be adapted to assess key complaints in context.
The CBT protocol itself may be structured in a way that takes into consideration
the domains in Table1, and the CBT protocol may ask participants about some of
these domains. For example, in our CBT treatment (Hinton, Rivera, etal., 2012), we
specically ask participants whether they are using any other means to cope with
Culturally Sensitive CBT forRefugees: Key Dimensions
216
distress, which often may be techniques from local religious traditions, and we use
probes to elicit key somatic complaints and local catastrophic cognitions.
In summary, treatment developers can review the parameters presented in this
chapter to further rene treatment at each stage of development of contextually sen-
sitive CBT. The parameters can also be used to assess the cultural sensitivity of
extant CBT treatments and treatment studies. However, the extent to which contex-
tually sensitive CBT as operationalized in this chapter improves efcacy needs to be
determined. One meta-analytic review (Benish et al., 2011) gave support for
increased efcacy with cultural adaptation of treatment elements, in particular, elic-
iting the client’s explanatory model of the disorder, but more studies need to be done
to see how and why the various parameters of culturally sensitive treatments in
general, and contextually sensitive CBT in particular, improve treatment outcomes.
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Devon E.Hinton, MD, Ph.D., is an anthropologist and psychiatrist, and an Associate Professor of
Psychiatry at Massachusetts General Hospital, Harvard Medical School, and the Department of
Global Health and Social Medicine, Boston, Massachusetts. He has researched extensively cultur-
ally sensitive assessment and treatment of trauma.
Anushka Patel, M.A., is a doctoral student of clinical psychology at The University of Tulsa,
OK.Her passions include examiningtrauma-related sequelae in low-income settings with cultural
minorities, so as to inform cultural adaptation of treatment in these groups.
Culturally Sensitive CBT forRefugees: Key Dimensions
... 19 Our model strives to develop a culturally-adapted SCCM, filling an existing gap by addressing major barriers in the availability and delivery of tailored psychiatric treatments for refugees and asylum seekers. 25,26 Therefore, the Mental Health in Refugees and Asylum Seekers (MEHIRA) study, a multi-centre, randomized, controlled trial intended to evaluate the effectiveness of a SCCM, in which interventions were allocated according to disease severity at four levels. Within this study, interventions were developed specifically for refugees with depressive symptoms of different severities. ...
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... The use of blended treatments of non-traditional and traditional services would benefit individuals who hold traditional values and beliefs. The use of culture specific examples and/or symbols have more meaning to patients and are easier for the patient to comprehend, rather than using western terminologies and examples (Hinton & Patel, 2018). The results of this study confirm the connection that participants felt to their therapist because they understood their culture, using culture specific examples and explanations. ...
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"Thinking a lot" (TAL)-also referred to as "thinking too much"--is a key complaint in many cultural contexts, and the current article profiles this idiom of distress among Cambodian refugees. The article also proposes a general model of how TAL generates various types of distress that then cause PTSD-type psychopathology, a model we refer to as the TAL-PTSD model. As tested in this Cambodian refugee sample, the model is supported by the following: (1) the close connection of TAL to PTSD as shown by odds ratio (OR = 19.6), correlation (r = .86), and factor loading; and (2) the mediation of most of the effect of TAL on PTSD by TAL-caused somatic symptoms, catastrophic cognitions, trauma recall, insomnia, and irritability. The questionnaire used in the present study is provided and can be used to examine TAL in other cultural and global contexts to advance the study of this commonly encountered distress form. [idioms of distress, "thinking a lot," "thinking too much," Cambodian refugees, PTSD] This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
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In this paper, I describe an embodied form of emotional distress expressed by Nicaraguan grandmothers caring for children of migrant mothers, "pensando mucho" ("thinking too much"). I draw on ethnographic fieldwork and semi-structured exploratory interviews about pensando mucho conducted with grandmother heads-of-household to show the cultural significance of this complaint within the context of women's social roles as caregivers in transnational families. Adopting an interpretive and meaning-centered approach, I analyze the cultural significance of pensando mucho as expressed through women's narratives about the impacts of mother outmigration on their personal and family lives. I show how women use pensando mucho to express the moral ambivalence of economic remittances and the uncertainty surrounding migration, particularly given cultural values for "unity" and "solidarity" in Nicaraguan family life. I also discuss the relationship between pensando mucho and dolor de cerebro ("brainache") as a way of documenting the relationship between body/mind, emotional distress, and somatic suffering. The findings presented here suggest that further research on "thinking too much" is needed to assess whether this idiom is used by women of the grandmother generation in other cultural contexts to express embodied distress in relation to broader social transformations.