Cognitive-Behavioral Therapy With Chinese Americans: Research, Theory, and Clinical Practice

doi:10.1016/j.cbpra.2006.04.010

Cognitive and Behavioral Practice

Volume 13, Issue 4, November 2006, Pages 293-303

https://doi.org/10.1016/j.cbpra.2006.04.010 Get rights and content

Abstract

In this article, we discuss how to conduct cognitive-behavioral therapy with Chinese Americans. We present an integration of theory, research, and clinical practice to help mental health practitioners understand how Chinese culture may potentially influence the CBT treatment process for Chinese immigrants. Several recommendations are provided as to how to adapt and modify CBT to better meet the therapeutic needs of Chinese American clients. A case example demonstrates how cultural modifications of CBT can lead to effective psychotherapy outcomes for Chinese American clients.

Section snippets

Chinese Americans and Mental Health

According to the 2000 census, there are approximately 12 million Asian Americans in the U.S., with people of Chinese ancestry comprising the largest group (2.7 million) (Barnes & Bennett, 2002). As a whole, Asian Americans are the fastest growing ethnic group in the U.S. and it is projected that their numbers will quadruple by the year 2050. While there are many similarities among the 43 ethnic groups encapsulated under the pan-ethnic label of “Asian American” (Lee, 1998), it is important not

Treatment Studies

To our knowledge, no randomized controlled trials examining the efficacy of CBT or other ESTs have been conducted on Chinese Americans. This gap in the literature is reflected by reviews of the overall treatment literature on Asian Americans, which tend not to differentiate among the different Asian ethnic groups, and are limited to descriptions of naturalistic treatment outcomes. The extant literature indicates that Asian Americans are less likely than other ethnic groups to seek treatment (

CBT and Chinese Americans

Chinese American mental health scholars have hypothesized that CBT may be more compatible with Asian culture and belief systems than other therapies (Lee, 1997b, Leong, 1986; Y. Lin, 2001). Although this belief has yet to be empirically tested, CBT seems to be one of the more popular treatment approaches used to treat clients of Chinese descent (Y. Lin, 2001) and may be preferred over psychodynamic approaches because it is more structured, directive, and symptom focused (Hong & Ham, 2001).

For

Case Study

Billy, a 12-year-old Chinese American male, was referred to a university mental health clinic by his pediatrician and child neurologist after experiencing 2 weeks of medically unexplained retrograde amnesia, drop attacks, and apparent loss of consciousness for several minutes followed by confusion and agitation lasting an hour. A drop attack is a medical symptom—not a diagnosis—involving a sudden spontaneous fall while standing or walking. In most American patients, drop attacks are not

References (48)

F.M. Cheung et al.
Situational variations of help-seeking behavior among Chinese patients
Comprehensive Psychiatry
(1982)
F. Frankel et al.
Parent-assisted transfer of children’s social skills training: Effects on children with and without attention-deficit hyperactivity disorder
Journal of the Academy of Child and Adolescent Psychiatry
(1997)
F.X. Acosta et al.
Preparing low-income Hispanic, Black, and White patients for psychotherapy: Evaluation of a new orientation program
Journal of Clinical Psychology
(1983)
American Psychological Association Task Force on Psychological Intervention Guidelines
Template for developing guidelines: Interventions for mental disorders and psychological aspects of physical disorders.
(1995)
K.V. Bui et al.
Ethnic minority adolescents and the use of community mental health care services
American Journal of Community Psychology
(1992)
P.M. Barrett et al.
Family treatment of childhood anxiety: A controlled trial
Journal of Consulting and Clinical Psychology
(1996)
J.S. Barnes et al.
The Asian population: 2000.
(2002)
F.M. Cheung
An overview of psychopathology in Hong Kong with special reference to somatic presentation
L.A. Evans et al.
Orienting psychotherapists to better serve low income and minority patients
Journal of Clinical Psychology
(1984)
H.A. Exum et al.
Counseling style preference of Chinese college students
Journal of Multicultural Counseling and Development
(1988)

J.H. Flaskerud et al.

Effects of an Asian client-therapist language, ethnicity, and gender match on utilization and outcome of therapy

Community Mental Health Journal

(1991)

M.D. Ham

Immigrant families and family therapy

Journal of Strategic and Systemic therapies

(1989)

G.K. Hong

Synthesizing Eastern and Western psychotherapeutic approaches: Contextual factors in psychotherapy with Asian Americans

G.K. Hong et al.

Psychotherapy and counseling with Asian American clients: A practical guide

(2001)

Y.N. Hong

Chinese saying told in pictures

(1987)

T.W. Hu et al.

Ethnic populations in public mental health: Services choice and level of use

American Journal of Public Health

(1991)

G.Y. Iwamasa et al.

AABT and ethnic diversity: A review of convention programs of the past decade

the Behavior Therapist

(1995)

G.Y. Iwamasa et al.

Ethnic diversity in behavioral psychology: A review of the literature

Behavior Modification

(1996)

C.A. Kearney

School refusal behavior in youth: A functional approach to assessment and treatment

(2001)

A. Kleinman et al.

Somatization: The interconnections in Chinese society among culture, depressive experiences, and the meanings of pain

E. Lee

Overview: The assessment and treatment of Asian American families

E. Lee

Chinese American families

S.M. Lee

Asian Americans: Diverse and growing

Population Bulletin

(1998)

F.T.L. Leong

Counseling and psychotherapy with Asian-Americans: Review of the literature

Journal of Counseling Psychology

(1986)

Cited by (54)

Utilizing Community Partnerships to Devise a Framework for Cultural Adaptations to Evidence-Based Mental Health Practice in Diverse Communities
2022, Cognitive and Behavioral Practice
Citation Excerpt :
This particular outcome is a complex one, in terms of its utility. On one hand, diverse communities have been siloed and examined separately under the understanding that the differences between these groups are too great to appreciably examine them all together, resulting in several community-specific treatment frameworks (Bernal et al., 2009; Hwang et al., 2006; Wood et al., 2008). On the other hand, it is this very separation of diverse communities that has perpetuated health disparities because often the individual numbers of diverse communities are so much smaller that their needs and requirements are not structurally addressed (Chou et al., 2012; Hatzenbuehler et al., 2017; Sibrava et al., 2019).
Mental health disparities for diverse communities (particularly immigrants and people of color) in terms of access to evidence-based treatments, lack of education/awareness about mental health symptoms and treatment options, and lack of culturally responsive treatments have been frequently documented. Hence, diversity considerations in the diagnosis, assessment, and treatment of psychological disorders remain vital and imperative in clinical practice. There is also substantial work indicating that cultural values likely play an essential role in shaping how individuals conceptualize and experience mental or emotional health. Therefore, the present study was developed for community-engaged clinicians and researchers to outline the process by which to create a culturally responsive, evidence-based treatment framework for community mental health interventions in close partnership with communities of color. This study was conceptualized and designed collaboratively with community leaders across five different communities of color: African American/Black, Latino/a, Native American, Pacific Islander, and African immigrant communities in a major U.S. city. This paper describes the mixed methods for such a community-engaged collaboration, highlighting critical elements for ongoing culturally engaged clinical work/research, and providing recommendations for culturally adapted interventions for mental health based on specific process observations made in the current example.
Adaptation of Transdiagnostic CBT for Turkish Adolescents: Examples From Culturally Adapted Multiplex CBT
2019, Cognitive and Behavioral Practice
Citation Excerpt :
By assessing the TSSA items and by informing the patient that the symptoms will improve, the patient knows the treatment will address key areas of concern, which increases positive expectancy. To promote positive expectancy, we also use analogies of CBT processes to local practices, a form of explanatory model bridging (Hinton & Jalal, 2014a; Hinton, Lewis-Fernández, Kirmayer, & Weiss, 2016; cf. Hwang, Wood, Lin, & Cheung, 2006, proposed as cultural bridging; Jalal, Samir, & Hinton, 2016). As one example of using such bridging analogies, in multiplex CBT, treatment is compared to the making of a special local dish that involves multiple culinary steps in order to promote positive expectancy and to teach patience about the time frame of improvement.
The present article illustrates how cognitive-behavioral therapy (CBT) was adapted for an adolescent Turkish population with mood and anxiety disorders. The resulting 10-session treatment—based on multiplex CBT—was efficacious in a treatment trial, showing large effect sizes (Acarturk et al., 2018). This paper discusses the cultural grounding of CBT, which increases effectiveness by such means as increasing acceptability and positive expectancy. We describe a culturally sensitive assessment measure of somatic complaints and cultural syndromes, the Turkish Symptom and Syndrome Addendum. We discuss how, in a culturally sensitive way, we normalized symptoms, conducted interoceptive exposure, and created positive reassociations to sensations. We describe how we used Turkish metaphors and religious ideas to teach CBT principles. We show how we adapted mindfulness and “loving kindness” for a Turkish population, and how we utilized transition “rituals” at the end of the treatment to give a sense of closure and a positive feeling of transformation. Two case examples are provided to further illustrate how we adapted multiplex CBT to a Turkish adolescent population.
Adaptation of CBT for Traumatized South African Indigenous Groups: Examples from Multiplex CBT for PTSD
2018, Cognitive and Behavioral Practice
Citation Excerpt :
For instance, one should explain that the symptoms experienced that are labeled as “having problems with the head” are not due to bewitchment or curses but rather to anxiety and depression, thereby normalizing the disorder. Another way to normalize the treatment and create positive expectancy is to do explanatory model bridging by such means as depicting CBT principles in terms of locally salient practices, metaphors, proverbs, and analogies (Figure 4; Hinton & Jalal, 2014b; Hinton, Lewis-Fernández, Kirmayer, & Weiss, 2016; Jalal, Samir, & Hinton, 2017; cf. to cultural bridging as proposed by Hwang, Wood, Lin, & Cheung, 2006). Explanatory model bridging is a key aspect of cultural grounding of CBT (Hinton & Jalal, 2014b; Hinton, Lewis-Fernández, Kirmayer, & Weiss, 2016; Jalal et al., 2017).
This article describes how Culturally Adapted Multiplex CBT, a treatment that emphasizes somatic processing and emotion regulation, was adapted for a traumatized South African indigenous group, the Sepedi. A model of psychopathology is presented, the Multiplex Model of Trauma-Related Disorder, which depicts the processes that generate multiple comorbidities and prominent somatization in minority, refugee, and other non-Western populations. The nine dimensions of Culturally Adapted Multiplex CBT are discussed, and so too the “cultural adaptation diamond.” Concepts such as “explanatory model bridging” are presented. A culturally sensitive assessment measure of local somatic complaints and cultural syndromes (the Sepedi Symptom and Syndrome Addendum, or Sepedi SSA) is detailed, as well as how CBT techniques were implemented with this group—for example, modification of culturally specific catastrophic cognitions, doing exposure (e.g., interoceptive exposure), teaching attentional control and mindfulness techniques, and teaching “loving kindness.” Case examples with clinical outcomes are provided to further illustrate how Multiplex CBT was adapted for the South African indigenous group.
Culturally Sensitive Adaptations to Evidence-Based Cognitive Behavioral Treatment for Social Anxiety Disorder: A Case Paper
2017, Cognitive and Behavioral Practice
Cognitive Behavioral Group Therapy (CBGT), which involves restructuring maladaptive thoughts and exposures in social contexts in a group format, is an empirically supported treatment for social anxiety disorder (SAD). However, research on applying these skills to experiences of discrimination that may contribute to social anxiety in marginalized populations is limited. A case description is presented to demonstrate the ways in which culturally sensitive adaptations of CBGT were applied to treat social anxiety related to issues of discrimination. The case example includes outcome data from one individual diagnosed with SAD who experienced clinical improvement in symptoms of SAD after receiving CBGT as a part of a larger treatment trial for SAD. Specifically, this paper focuses on the way in which SAD manifested for a Latina woman based on a history, and current context of race-based and gender-based discrimination. We present strategies to address SAD related to experiences of discrimination within the context of CBGT as well as clinical implications related to the integration of multicultural principles and traditional cognitive behavioral therapies for SAD more generally.
Adaptation of CBT for Traumatized Egyptians: Examples from Culturally Adapted CBT (CA-CBT)
2017, Cognitive and Behavioral Practice
Citation Excerpt :
Another way to normalize the treatment and create positive associations and expectancy about the treatment is to provide certain descriptions of the entire treatment and about its specific elements, and to ground them in terms of locally salient practices and metaphors, what may be called “cultural grounding.” Doing so might involve using bridging analogies or bridging metaphors in the service of explanatory model bridging (cf. to cultural bridging as proposed by Hwang, Wood, Lin, & Cheung, 2006; see Figure 1). For example, in CA-CBT, treatment is compared to the making of a special local dish that involves multiple culinary steps in order to promote positive expectancy and to teach patience about the timeframe of improvement.
In this article we illustrate how CBT can be adapted to a traumatized Egyptian population with Islamic beliefs, giving examples from our adaptation of Culturally Adapted–CBT (CA-CBT) for this cultural group. We discuss a culturally sensitive assessment measure of local somatic complaints and cultural syndromes that was devised based on clinical experience with traumatized Egyptians. We also demonstrate how to normalize symptoms, create positive expectancy about the treatment, and educate about trauma. We give examples of how mindfulness can be adapted for an Egyptian Islamic population, and we describe local religious strategies, such as dhikr (religious chanting), salah (ritualistic prayer), and dua (supplication), that may be used to promote attentional shift from rumination topics and to teach attentional control. We describe how “loving kindness” can be adapted for this group. We outline how to modify culturally generated catastrophic cognitions and how to conduct interoceptive exposure and to create positive re-associations in a culturally sensitive manner. We describe how worry themes are explored and addressed based on a heuristic panic attack–PTSD model; how to teach anger management in a culturally sensitive way; and how to address sleep-related problems in this population. We suggest using cultural transitional “rituals” at the end of the treatment to give patients a sense of closure and a positive feeling of transformation. A case example is presented to illustrate cultural challenges associated with delivering CA-CBT to an Egyptian population. We introduce certain concepts such as cultural grounding and explanatory model bridging, both therapeutic techniques that increase adherence, positive expectancy, and cultural consonance.
Ethnic differences in the effectiveness of cognitive behavioral therapy combined with medication: Comparing Asian American and white psychiatric patients
2016, Asian Journal of Psychiatry
Citation Excerpt :
Sue et al. (2012) finds a gap in what is known about the mental health status and psychotherapy treatment of the Asian American population. As CBT is directive, short-term, and action-oriented, it is thought to be culturally congruent with Asian clients’ expectations of therapy (Hong and Ham, 2001; Hwang et al., 2006). A recent study (Tang et al., 2015) found CBT combined with medication to be an effective treatment for Asian American (AA) patients within an acute psychiatric partial hospital setting.
Several meta-analyses have demonstrated the effectiveness of treatment utilizing cognitive behavioral therapy (CBT) combined with medication. There is, however, a paucity of research comparing the effectiveness of this combined treatment with psychiatric patients from different ethnic backgrounds. This study is the first of its kind to compare the effectiveness of CBT combined with medication for Asian American and White patients’ psychiatric symptom severity levels of depression, anxiety, psychological well-being, and quality of life. The study examined the effects of CBT combined with medication for 43 Asian American and 43 White Non-Hispanic patients at an acute psychiatric partial hospital. A 2 × 2 between-within repeated measures analysis of variance was used. Results indicated significant improvement after treatment in all symptom categories assessed for the Asian American and White patients. The findings displayed trends over the course of treatment toward a greater decrease in anxiety symptoms among Asian patients but a larger increase in functioning level among White patients. In conclusion, the findings from this study provide preliminary cross-cultural support for CBT combined with medication as a treatment in partial hospital settings and suggest that the effectiveness of such treatments is similar across cultural groups.

View all citing articles on Scopus

View full text

Cognitive-Behavioral Therapy With Chinese Americans: Research, Theory, and Clinical Practice

Abstract

Section snippets

Chinese Americans and Mental Health

Treatment Studies

CBT and Chinese Americans

Case Study

Comprehensive Psychiatry

Journal of the Academy of Child and Adolescent Psychiatry

Preparing low-income Hispanic, Black, and White patients for psychotherapy: Evaluation of a new orientation program

Journal of Clinical Psychology

Template for developing guidelines: Interventions for mental disorders and psychological aspects of physical disorders.

Ethnic minority adolescents and the use of community mental health care services

American Journal of Community Psychology

Family treatment of childhood anxiety: A controlled trial

Journal of Consulting and Clinical Psychology

The Asian population: 2000.

An overview of psychopathology in Hong Kong with special reference to somatic presentation

Orienting psychotherapists to better serve low income and minority patients