Abstract
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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Notes
- 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 encouraged 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 therapeutic by both local and “scientific” standards. Note that addressing concerns about a depleted or inauspicious spiritual status is often part of addressing catastrophic cognitions because the perception 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.
- 3.
The attempt at bridging, which requires eliciting the client’s explanatory model, is seemingly efficacious 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 cognitions 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).
- 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 victim. It should be noted that local models like that of karma may be used as a justificatory frame for perpetration of violence and need to be addressed at the community level. More generally, stigmatization of the survivor may need to be addressed at various levels such as through finding group consensus and utilizing local religious and transnational human-rights frames.
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Hinton, D.E., Patel, A. (2018). Culturally Sensitive CBT for Refugees: Key Dimensions. In: Morina, N., Nickerson, A. (eds) Mental Health of Refugee and Conflict-Affected Populations. Springer, Cham. https://doi.org/10.1007/978-3-319-97046-2_10
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