Culturally Responsive Cognitive Behavioral Therapy

Abstract

This case study provides an analysis of culturally responsive cognitive behavioral therapy with a 15-year-old African American female. The focus of this case study is on the course of treatment and how it was influenced by the implementation of the Jones Intentional Multicultural Interview Schedule (JIMIS)—a process that was completed at the beginning of treatment. A total of 20 therapy sessions were recorded and transcribed for the analysis. The research team analyzed the data qualitatively by identifying culturally salient codes that were stated within each session and coding transcripts using Dedoose software version 6.1.18. Results showed that four culturally salient codes were prominent throughout treatment and that these codes were strongly related to African American culture: gender norms, informal kinship, socioeconomic status, and race/ethnicity. The connections between the coded themes, the cultural values of the client, as well as the implications for treatment outcomes are described. This study provides evidence of the value of initiating discussion of cultural factors at the beginning of treatment to shape the direction of evidence-based treatment. The study also suggests that integrating cultural factors with African American clients is important and does not reduce the quality of care or diminish from the fidelity of the evidence-based treatment. Based on these findings, recommendations for researchers and clinicians are also discussed.

Keywords

culturally responsive therapy cultural factors evidence-based treatment

1 Theoretical and Research Basis for Treatment

As the population continues to grow more linguistically and culturally diverse, practitioners are seeking ways to integrate culturally responsive practices into evidence-based treatments, as both are necessary elements to providing effective treatment (Cabassa & Baumann, 2013). However, few studies describe the integration of both evidence-based treatments and culturally responsive treatment methods. Evidence-based treatments focus on the importance of implementation fidelity and efficacy of contextual aspects to mental health care, whereas culturally responsive mental health treatments fit clients’ and practitioners’ cultural background, including age, cultural values, gender, language, race, and sexual orientation (Cabassa & Baumann, 2013). Research has shown that integrating culturally responsive practices into counseling or psychotherapy can have a positive impact on treatment outcomes (López, Shealy, & Rheingold, 2014). For instance, Piña-Watson, López, Ojeda, and Rodriquez (2015) found that integrating ethnic identity and cultural variables such as Familismo into therapy sessions positively influenced academic motivation in a group of Mexican American high school students. Other studies have shown similar positive results (González-Prendes, Hindo, & Pardo, 2011; Weiss, Singh, & Hope, 2011) for other ethnic minority groups, such as Asian Americans (Wang & Kim, 2010) and African Americans (Coard, Wallace, Stevenson, & Brotman, 2004; Ecklund & Johnson, 2007; González-Prendes & Thomas, 2009).

Cognitive behavioral therapy (CBT) is an evidence-based treatment for treating individuals with depression, anxiety, bipolar disorder, and other mental health problems (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Within the broader CBT framework, culturally responsive cognitive behavioral therapy (CR-CBT) is a form of psychotherapy that has integrated culturally responsive factors into the delivery of traditional CBT. That is, in contrast to the traditional CBT, CR-CBT takes into account the ethnic and cultural values and beliefs of the client to tailor the intervention to the unique situation of the individual (Hays, 2009). When providing CR-CBT, the clinicians have to become aware of their own cultural bias as well as the customs and beliefs of their client to enhance the therapeutic working alliance (Hays, 2009). Another well-known culturally responsive intervention is multicultural counseling, which emerged as an effective model of therapy not only for ethnic minority groups (African Americans, American Indians, Asian Americans, and Latinos) but also for sexual minorities (including lesbian, gay, bisexual, transgender, and questioning) and other special populations (Sue, Arredondo, & McDavis, 1992). In multicultural counseling, the therapist is someone who is constantly aware of his or her own cultural bias, understands the different beliefs and values of his or her clients, and engages in training to develop and foster skills to work with culturally diverse clients (Sue & Sue, 2016).

The positive effects of culturally responsive evidence-based treatments on clients have been well documented. A recent study by Hinton, Hofmann, Rivera, Otto, and Pollack (2011) showed that Latino women who received culturally adapted CBT experienced significant decrease in symptoms associated with posttraumatic stress disorder (PTSD) compared with the control group who received muscle relaxation treatments. During the culturally adapted CBT treatment, Hinton and colleagues (2011) found that the use of culturally adapted idioms and analogies consistent with the client’s cultural background were significantly related to a reduction in PTSD symptoms. Similarly, evidence-based treatments that involve cognitive restructuring have found that for bilingual clients, the analysis of initial thoughts and homework assignments should be completed in their primary language because many individuals think and interact in their primary language first (Weiss, Singh, & Hope, 2011). In addition, a meta-analysis conducted by Benish, Quintana, and Wampold (2011) also suggested that larger effect sizes were found when analyzing published and unpublished studies that included cultural adaptation with conventional treatments compared with studies that used only conventional treatments to racially and ethnically diverse clients. Rather than implementing conventional treatment method, therapy works more effectively when involving culturally responsive factors in the conceptualization of clients’ presenting problems because mental health issues are usually culturally related (Benish et al., 2011). Moreover, Benish et al. (2011) argued that mental disorders are shaped by culturally related experiences; therefore, treatments should also be culturally appropriate in order to be aligned with the actual ingredients of the symptoms. Based on this research, it seems that therapy would not be as effective without incorporating culturally responsive factors. Thus, the integration of culturally responsive practices is crucial, especially when dealing with clients from culturally diverse backgrounds (Benish et al., 2011; Cabassa & Baumann, 2013; Hinton et al., 2011).

When implementing culturally responsive therapy, it is important for practitioners to be aware and understand that each cultural and ethnic group has their own values and beliefs that affect their identity development and the experiences they go through in everyday life (Cheng, Carter, & Lee, 2015; Iwamoto, Negi, Partiali, & Creswell, 2013). A culturally responsive therapist is someone who is constantly aware of his or her own cultural bias, who is always trying to understand the different beliefs and values of his or her clients, and who is always engaging in training to develop and foster skills to work with his or her culturally diverse clients (Sue & Sue, 2016). Some researchers have provided evidence of the client desires to receive culturally responsive treatment. For example, some studies have shown that ethnic minority clients have a moderately strong preference for clinicians with same ethnic background (Cabral & Smith, 2011) while other studies show that ethnic minority perceptions of whether a clinician respects and takes into consideration their cultural beliefs (Wang & Kim, 2010) is more important. Interestingly, research has found that having same-race therapists had almost no effect on treatment outcomes in minority populations, with the exception of African Americans who reported “mildly better” therapy outcomes (Cabral & Smith, 2011). Furthermore, Atkinson, Wampold, Lowe, Matthews, and Ahn (1998) found that people ranked ethnic similarity as less important than other factors such as values, attitudes, beliefs, and worldview.

Cultural Influences in the Therapy Process

In the therapeutic process, culture encompasses much more than race; it is the interaction of a variety of factors related to culture that affects the client–therapist relationship (Jones, Begay, Nakagawa, Cevasco, & Sit, 2015). The ADDRESSING factor framework, a clinician-oriented approach or technique created by Pamela Hays (2016) facilitates the clinicians’ ability to address various cultural influences during counseling or psychotherapy. According to Hays (2016), the multicultural framework encompasses two broad categories: personal work and interpersonal work. The first category, personal work, entails the clinician’s self-exploration of values and beliefs and how culture has influenced his or her belief system and understanding of the world. The second category, interpersonal work, emphasizes on the therapist’s learning from other cultures, usually through interpersonal experiences (Hays, 2016). The cultural factors of the ADDRESSING framework include age/generational influences, developmental or other disability, religion and spiritual orientation, ethnic and racial identity, socioeconomic status, sexual orientation, indigenous heritage, national origin, and gender (Hays, 2016). According to Hays, by addressing these cultural influences during therapy, clinicians can become more aware and cautious about the limitations of their knowledge and experiences of other minority groups. In addition, using the ADDRESSING framework enables the clinicians to learn about how their clients’ culture has influenced their lives (Hays, 2016). Thus, using the ADDRESSING framework can not only facilitate a deeper understanding of the client, but it also increases the multicultural counseling competencies of the clinicians by encouraging the clinicians to think about how culture, socioeconomic status, customs, values, and beliefs have impacted their own development in addition to that of the client.

The Jones Intentional Multicultural Interview Schedule (JIMIS; Jones, 2009) can be used to structure the initial therapeutic sessions. According to Jones (2009), using the interview schedule can serve as a guide for mental health providers to get to know the client better in a culturally responsive way. Each section of questions in the JIMIS is aligned with each construct of the ADDRESSING framework. That way, clinicians are able to talk about all the cultural factors included in the framework in a more structured manner.

The aim of this clinical case study was to determine how the intentional integration of cultural factors during the interview and rapport building phase of therapy impacts the school-aged client’s initiation of cultural factors throughout treatment. The clinician who worked with this client had previously received training in CBT, the primary evidence-based treatment approach. Prior to the start of treatment, the clinician received a refresher course in CBT in addition to receiving training in the ADDRESSING framework and how to use the JIMIS. Table 1 shows the relationship between the ADDRESSING Framework and the JIMIS. There were a total of 20 sessions, which were all video recorded and transcribed. The clinician was supervised by a licensed psychologist with expertise in CBT and multicultural counseling.

Table 1.

ADDRESSING Framework and the JIMIS.

ADDRESSING frameworkCultural influences	Application to minority groups	Sample questions from JIMIS
Age/generational influences	Children, older adults	How do you define family? Who is in your family? Who lives in your home? What do your family members call you? Where were you born? Where does most of your family live now? Who makes the decisions about your daily care (e.g., transportation, food, discipline)?
Developmental or other disability	People with cognitive, intellectual, sensory, physical, and psychiatric disabilities	What are some challenges that you or your family members have to deal with? Tell me what you think about school. What emotions come to mind when you think about your schoolwork?
Religion and spiritual orientation	Muslims, Jews, Hindus, Buddhists, and other religions	How does your family deal with feelings? What are some coping strategies that they use? How do religion and spirituality impact your family? Who do you turn to when you are sad, scared, or worried about something?
Ethnic and racial identity	Asian, South Asian, Latino, Pacific Islander, African, Arab, African American, Middle Eastern, and multiracial people	What does your family think about counseling? What do you think about it? What are some things about your family that few people know? How do you describe yourself in terms of your race? How does your race affect your relationships with other people? What issues do you have with hair and/or skin color? What experiences do you have with racial conflict? Who supports you the most at school? At home?
Socioeconomic status	People of lower status by occupation, education, income, or inner city or rural habitat)	If you were to choose a job today, what would it be? Would your family approve of this job? What would your family prefer for you to do when you grow up? What is a job you would like to do, but would never choose it?
Sexual orientation	People who identify as gay, lesbian, or bisexual	What are some characteristics about you that make you similar or different from people in your peer group? Is there a label that your peers use to describe groups of kids at your school? Which label best identifies your group?
Indigenous heritage	American Indians, Inuit, Alaska Natives, Métis, Native Hawaiians, New Zealand Māori, Aboriginal Australians	What are some rituals/routines that your family does daily? Which are used to cope with stress? What situations are most stressful for you?
National origin	Refugees, immigrants, international students	How and when did your family arrive in the United States? What were the circumstances of their arrival?
Gender	Women and people who identify as transgender	When there is conflict with peers at school, what is the usual cause? What are some characteristics about you that make you different from people in your peer group? What do you believe are the responsibilities of women or men?

Source. See Hays (2016) for a comprehensive description of the ADDRESSING framework. See Jones (2009) for the complete JIMIS. Adapted with permission.

Note. JIMIS = Jones Intentional Multicultural Interview Schedule.

2 Case Introduction

“Audra” was a 15-year-old African American girl who was in 10th grade. She lived with her mother and her brother (12 years old) and sister (10 years old) in an apartment in Seattle, WA. Her family moved from Atlanta to Seattle after her parents’ divorce around 6 years prior to the initiation of treatment. Audra’s mother (“Mrs. G”) described Audra as sociable, smart, adventurous, and as someone who has a “caring soul.”

Audra’s clinician was a mixed race (African American and Caucasian American) woman in training to be a doctoral-level clinical social worker. She was in the fourth year of her PhD program and was seeking additional supervised experiences in providing counseling services to adolescents. The dyad between Audra and this clinician was part of a larger study (Jones, Begay, Nakagawa, & Sit, 2015) that also addressed cultural competency building in clinicians as a part of providing counseling services to adolescents with depression.

3 Presenting Complaints

Mrs. G contacted the principal research study investigator due to concerns about her relationship with her daughter as well as her daughter’s anger management problems. She reported that her daughter gets anxious, overwhelmed, and frustrated easily with people when experiencing stress. In addition, she reported that Audra was experiencing major headaches and that she tends to withhold affection and hide her feelings. Audra also reported that she experiences high levels of irritability, anger, and changes in mood. Moreover, Audra also reported that she sometimes worries about school, feels lonely and sad, and sometimes feels that life is unfair and like running away.

4 History

Audra was born and raised in Georgia. According to Mrs. G, Audra was born healthy and she met developmental milestones within the typical time frame. She is the oldest of three siblings. When Audra was 6 years old, Mr. and Mrs. G separated due to constant arguments, which sometimes involved violence. Audra was 7 years old when her parents divorced and the family decided to move to Seattle. After the divorce, Audra received counseling services for a few months to help her cope with the situation and new family changes. Mrs. G conveyed not being sure whether the counseling was helpful for Audra, but it did seem to provide a safe space for Audra to talk. Since living in Seattle, Audra has been attending the same school, even though the family has moved residences four times. According to Mrs. G, Audra’s father lives in California and visits his children once a year. In Seattle, the family lives close to the children’s maternal grandmother’s house.

Mrs. G reports that Audra is like a “social butterfly” and does not have any problems with friends; however, she tends to argue a lot with her mother and siblings at home. Mrs. G also reported that Audra usually overreacts when faced with a problem and gets mad when things are not going well with her “best friends” and when Mrs. G questions her about things. One of the most distressful behaviors to Mrs. G is the fact that Audra tends to stay with her maternal grandmother and does not want to be at home. From Audra’s perspective, her primary concerns are that she has experienced panic attacks in the past, feelings of irritability and anger, and her low-tolerance for males.

Recent changes in Audra’s environment has been her sister’s recent diagnosis of Type I diabetes (and a history of diabetes running in the family). According to Mrs. G, family attention has been shifted to the youngest daughter, so that might be causing some jealousy in Audra. Moreover, Mrs. G has been recently laid off from work, which has slightly affected insurance/medical coverage for the family.

5 Assessment

To assess Audra’s current strengths and challenges, both self-report and parent-reported behavior rating scales were completed. In addition, a clinical interview was completed with Mrs. G and Audra together and separately.

Prior to the clinical interview, the Behavior Assessment System for Children–Second Edition (BASC-2) was administered to both Audra and her mother. On the BASC-2 Self-Report (C. R. Reynolds & Kamphaus, 2006), Audra’s ratings resulted in scores in the at-risk range on the Inattention and Hyperactivity subscale (T score of 69). Specifically, Audra reported having some difficulty with staying on-task and regulating energy. However, Audra’s ratings yielded scores in the average range for the School Attitude, Internalizing Problems, and the Adaptive Skills subscales. On the BASC-2 Parent-Report, Mrs. G’s ratings produced average scores in all of the subscales, which means that Mrs. G did not perceive Audra as having significant internalizing or externalizing problems. Last, on the Reynolds Adolescent Depression Scale–Second Edition (RADS-2; W. M. Reynolds, 2002), Audra’s ratings yielded scores in the average range in the Dysphoric Mood, Anhedonia/Negative Affect, Negative Self-Evaluation, and Somatic Complaints subscales. However, Audra’s responses to some of the questions indicated the following problems: sometimes feeling lonely, sometimes worrying about school, sometimes feeling like running away, sometimes feeling that life is unfair, sometimes feeling mad about things, and often having trouble sleeping.

During the clinical interview, Audra presented with high irritability (especially with family members) and some symptoms associated with anxiety and depression. Audra experienced headaches, troubles with sleeping, and difficulty with staying on-task. Her affect was variable with periods of high affect, which could quickly switch to low affect. Also, Audra’s mood would become elevated when talking about social activity with specific groups of peers. Audra did not endorse suicidal or homicidal ideation. Last, Audra’s insight and judgment seemed age-appropriate and she was oriented to time and place. Audra’s symptoms appeared to meet criteria for both dysthymic disorder and generalized anxiety disorder. In particular, the persistent irritability, worry, and sleep disturbances were consistent with both disorders. For Audra, the clinician decided to focus on the overlapping symptoms and the intersection between depressive symptoms and anxiety symptoms.

6 Case Conceptualization

At the start of the treatment, the following behavior problems were identified: impaired communication between Audra and the family, high levels of irritability that manifest in conflictual relationships, and impaired ability to express feelings appropriately and ensuring that Audra’s needs are met. The family mutually decided that the focus of treatment will begin with the irritability and family relationships. Based on assessment results and information collected during the clinical interview, the goals of treatment were to increase communication between Audra and her mother, increase her ability to self-regulate and find appropriate outlets to express her emotions, and identify appropriate coping skills. To address these treatment goals, CR-CBT was provided once a week for a total of 20 sessions.

7 Course of Treatment and Assessment of Progress

Course of Treatment

Treatment was divided into three phases: the initial phase (Sessions 1-7) included the JIMIS as well an introduction to the foundations of CBT; the middle phase (Sessions 8-13) focused on supporting Audra to recognize her automatic thoughts, feelings, and behaviors through a culturally responsive lens; and the final phase of treatment (Sessions 14-20) was dedicated to introducing coping strategies and applying the principles of CBT to treatment goals. During the initial phase of treatment, the clinician applied the JIMIS to initiate discussion about cultural factors. The intention of this interview was not only to learn about Audra’s cultural identity and values but also to set the context where culture could be integrated into the remainder of therapy. During the first few sessions, Audra and the clinician developed treatment goals based on information Audra reported as being the most impactful in her everyday functioning. In addition to identifying goals, Audra disclosed several culturally relevant factors for the clinician to include throughout treatment. The following four cultural variables emerged early in the therapeutic process and remained salient throughout treatment: gender norms, informal kinship, socioeconomic status, and race/ethnicity. For instance, during the initial phase of treatment Audra often talked about the stress and pressure of taking birth control pills, her reliance on her grandmother and extended family, the influence of her family’s financial instability on her relationship with her mother, and how her race impacts her relationship with others. Another culturally responsive tool that was used to help elicit more about these cultural values was the use of an Ecomap (Hartman, 1995). An Ecomap is an interviewing technique where the clinician and client together develop a visual representation of the client’s sociocultural and ecological system. The ecological system is constructed around the client and shows the interactions between the client and his or her environment both in terms of cultural influences and relationships. The clinician, in this case, incorporated all family members, the strength and intensity of the relationships (both positive and negative), and the environmental stressors that affect the relationships. The Ecomap created an opportunity for the clinician and Audra to conceptualize how to cope with stress and express her emotions adaptively in each environment. Through identifying Audra’s cultural values and norms early in treatment, the clinician was able to introduce the foundations of CBT while being sensitive to cultural nuance.

During the middle phase of treatment (Sessions 8-13) the same four themes emerged highlighting the salience of culture throughout the therapeutic process. For instance, Audra heavily discussed her frustration with her mother for giving her “too many” chores, requiring her to get her own job (socioeconomic status) and for being so demanding with her grades (age/generational). Considering how Audra’s culture may impact some of her experiences supported the clinician in effectively teaching Audra how to recognize her automatic thoughts, feelings, and behaviors in different contexts.

In the final phase of treatment (Sessions 14-20), the same four cultural variables continued to surface as integral factors of treatment including the dual role her mother played in her life as both father and mother (gender roles) as well as the influence of informal kinship on her ability to cope (age/generational). During these sessions, the clinician challenged Audra’s automatic negative thoughts and introduced the Catch-Check-Change exercise. Through integrating different sources of support, such as extended family, as well as identifying the impact of Audra’s race and ethnicity on her everyday experiences, the clinician helped Audra to become aware of her own negative automatic thoughts, changing them, and shifting to a more adaptive thought or perspective. During the final sessions, the clinician included Audra’s mother in the therapeutic process and together they discussed strategies Audra and her mother could use to problem solve, improve communication, and support her in adaptively expressing herself.

Assessment of Progress (Procedure)

The research team qualitatively coded culturally salient codes initiated by Audra that appeared during the 20 sessions. To code the culturally salient words, the principal investigator and four graduate research assistants agreed upon specific definitions and examples of each of the cultural factors categorized in the ADDRESSING framework (Hays, 2016) and in the JIMIS (Jones, 2009). In the second phase of coding, the team used Saldaña’s (2016) definition of a code: “a word or short phrase that symbolically assigns a summative, salient, essence-capturing, and/or evocative attribute for a portion of a language-based or visual data” (pp. 3-4). That is, the nine cultural factor codes of the ADDRESSING framework were used to assign labels to summarize a passage of qualitative data. Using the qualitative data analysis processes of Miles, Huberman, Saldaña, and State (2014), the research team dual-coded transcripts of each therapy session by labeling passages with predefined culture factor codes of the framework. In order to manage the large amount of data, the research team used the qualitative software system Dedoose version 6.1.18. Dedoose software provided an electronic system to analyze the transcripts for keywords and themes within the sessions by assigning labels to passages. Each research team member assigned codes blind—They were unable to see the codes assigned by others on the team. This step allowed for the team to determine intercoder reliability. Intercoder reliability was measured between graduate research assistants and determined to be strong at .75.

Assessment of Progress (Themes)

After the coding process was complete, the research team analyzed the codes and organized based on the three phrases of therapy (initial, middle, and ending). The team assessed whether cultural factors remained a salient element of treatment across the three phases and what aspects of culture were pervasively contributing to the therapeutic process. Throughout the course of treatment for Audra, four culturally salient ADDRESSING codes were prominent: age/generational, socioeconomic status, gender, and race/ethnicity.

Figure 1 shows the total numbers of culturally salient codes used in therapy that align with the ADDRESSING framework (Hays, 2016) and JIMIS (Jones, 2009). Audra initiated discussion of gender and age/generational topics quite frequently. Overall, Audra addressed all of the culturally salient themes, with varying degrees, throughout treatment. However, four predominant cultural variables were evident throughout all three phases of treatment: age/generational, gender, socioeconomic status, and race/ethnicity. A pattern was observed across all cultural factors that indicated a large frequency of culturally salient codes in the initial phase of treatment, less in the middle of treatment, and an increase at the ending of treatment. The middle phase of treatment focused on identifying automatic thoughts and feelings, while the ending of treatment focused on application of the newly learned strategies and skills. The frequency of codes may suggest that Audra integrated aspects of her cultural self-most when the clinician was learning about Audra and then again when she was considering how to apply these skills. Figure 2 illustrates the frequency of four most culturally salient codes for each phase of treatment.

Figure 1.

Frequency of ADDRESSING framework codes by treatment phase.

Figure 2.

Frequency of four most salient ADDRESSING framework codes by treatment phase.

Coded theme: Age/generational

During the initial phase of treatment, Audra identified the role of formal kinship and in this case, her grandmother, in every session. Understanding how Audra viewed her grandmother’s home as her own home (González-Prendes et al., 2011) and that she often chose it as an escape when she was in conflict with her mother was essential to supporting the goal of increasing the positive communication with her mother. In addition to the role of her grandmother, Audra referenced her aunt’s role as caregiver in several initial sessions reflecting the importance of extended family in her daily functioning. In the middle phase of treatment, this culturally salient element was the most prevalent of all the coded cultural factors. During this critical phase in therapy, the clinician was able to use the strength of the relationship between Audra and her familial caregivers to develop healthy coping strategies for Audra’s negative cognitions (González-Prendes & Thomas, 2009). Finally, in the last phase of treatment, the cultural norm of informal kinship and caregiving roles remained salient. During this phase of treatment, Audra and clinician utilized these systems of support for Audra as a resource for building coping strategies.

Coded theme: Socioeconomic status

Throughout all three phases of treatment, the role of Audra’s socioeconomic status on her mental health remained prevalent. In the initial sessions, Audra described the stress financial poverty creates for her mother as a single parent as well as the feelings it elicits toward her father who abandoned the family at a young age. Uncovering the impact of living in an insecure socioeconomic climate supported the clinician in understanding the approach to treatment. For example, there was a constant discussion in the household about sharing resources, purchasing only necessities, and considering other family members before eating snacks or food in the refrigerator. During the middle phase of treatment, Audra described the physical space of her living environment as a root cause of the many of the negative interactions with her mother as well as the source of irritability when she was unable to seek out her own personal space as a coping mechanism. This often led to fluid transitions to alternative households (e.g., her grandmother’s) in order to “help out.” In the last phase of treatment, Audra revealed the stress of another primary caregiver, her aunt, having her house repossessed. The impact of this event may not have been viewed with the same level of significance had the clinician not initially identified the importance and cultural salience of this topic for Audra’s treatment. In fact, two primary goals of treatment were directly related to the role of poverty, a cultural element that continued to surface throughout therapy (Vergara-Lopez & Roberts, 2015).

Coded theme: Gender

Throughout treatment, cultural-based roles including the matriarchal structure remain salient. During the initial phase of treatment, Audra disclosed the feeling of needing to absorb the maternal role with her siblings and friends indicating her intention of continuing the same matriarchal structure of her childhood (Vergara-Lopez & Roberts, 2015). Audra identified her mother as a single parent, but as an adult who absorbs the role of both mother and father many times throughout treatment. In the final phase of treatment, this theme continued to surface and provided an opportunity for the clinician and client to discuss how Audra could integrate this part of her cultural identity in ways that are healthy and adaptive (González-Prendes & Thomas, 2009).

During the initial intake interview, this sexual identity did not surface as a primary source of conflict for her; however, it quickly became clear that this part of Audra’s lived experienced was a critical aspect of her treatment. In the initial phase of treatment, Audra evoked this theme mostly through discussion of her own sexualized identity. However, by the middle and last phase of treatment, Audra spends a significant amount of time discussing the significant thought distortions and feelings associated with being a sexualized object, her fears about having sexual intercourse, becoming pregnant too early as an African American girl (and enacting the stereotype; Vergara-Lopez & Roberts, 2015), and encounters that have contributed to her difficulty finding appropriate outlets for her emotions, a primary goal of treatment.

Coded theme: Race/ethnic identity

Topics related to race and ethnic identity were coded in all three phases of treatment suggesting that this aspect of Audra’s culture remained a salient element during therapy. During the initial phase of treatment, Audra described her environment and relationship to others by way of her racial phenotype (Ecklund & Johnson, 2007). For instance, Audra revealed that a prominent source of her irritability, a primary goal in treatment, related to being mistaken as mixed race or “half White” due to her light skin color. Without providing the initial therapeutic norm of talking about race (including skin color, hair styles and type, and other physical aspects of racial identity), it is unlikely that Audra would have felt the same comfort using these informal terms with the clinician. This is important not only for rapport building but also for creating a therapeutic environment in which Audra feels comfortable discussing all aspects of her experience (Ecklund & Johnson, 2007). During the middle of treatment, the shared racial phenotype of Audra and clinician was used as a means of building rapport between the clinician and the mother as well as Audra and clinician. Finally, in the last phase of treatment, Audra referred to the impact of stereotypes and her own hairstyles in reference to her coping strategies. This offered the clinician insights into how to support the ethnic identity development of Audra, a factor identified in the literature to be an essential factor in self-confidence and supporting resiliency among African American adolescents (Tynes, Umana-Taylor, Rose, Lin, & Anderson, 2012).

9 Access and Barriers to Care

As aforementioned, the parent of Audra had been recently laid off from work at the beginning of the treatment, which affected the family’s insurance coverage. In addition, the parent of Audra reported concerns about the amount and consistency of child support she was receiving from Audra’s father on a monthly basis. Thus, this economic situation significantly impacted the parent’s decision and need to seek for free counseling services for Audra. She was grateful when she heard about the clinical research study and sought the time-limited therapy that would be free of charge.

10 Follow-Up

A letter was mailed to each family after the end of treatment. The letter provided a summary of the scores from the screening measure and compared Audra’s self-ratings and her mother’s ratings of Audra both pre and post treatment. On the RADS-2 (W. M. Reynolds, 2002), Audra’s scores were in the average range at the end of treatment with minor fluctuations within the range. She showed a marginal increase in her self-rating of dysphoric mood and a significant decrease in score on the somatic complaints scale. Audra did not endorse any critical items. Furthermore, her mother’s ratings on the BASC at the end of treatment also showed that her emotional symptoms were diminished.

11 Treatment Implications of the Case

In the context of Audra’s treatment, our study provides evidence of the impact of cultural factors in the treatment of African American clients. Our study shows that there are nuances in the interpretation of behaviors and environmental variables that should be considered with a cultural lens. In this section, we identify each of the prominent themes and the related connections to African American culture.

Under the age/generational theme, Audra’s thematic content was highly reflective of kinship factors in African American culture. Audra and her mother were highly engaged in defining family as inclusive of both a formal and informal kinship structure. In African American communities, the kinship structure includes consistent accessing of resources such as extended family, community-based supports, and spiritual resources as support in daily interactions and parenting (Hill, 1999; Jones, 2007). Her lifestyle included fluid movement between households including her aunt, grandmother, and her nuclear family residence. This movement involved frequent adjustments between caregiver roles, different levels of responsibility for Audra, and altered communication patterns among the kinship community. The fluid movement and flexible family roles were a powerful example of an enactment of culture rather than pathologized by the clinician as what could be interpreted inadequate parenting resources (Sondhi, Gulgulia, & Shriharsh, 2013). In Audra’s case, the line of communication with her mother improved throughout treatment despite the fluid movement and flexible roles.

The socioeconomic status theme also revealed aspects of Audra’s culture. In particular, the intersectionality between family structure (single mother/absent father) and financial status was a key component of treatment. Even though the family structure was in line with stereotypes about African American families, the divided resources were a source of stress for all the women in the family, but also the children. Living in poverty was a source of anger and frustration for Audra as she linked the family financial status on her father’s “abandonment.” The financial insecurity was pervasive in all three households that Audra inhabited. As a result, her family interactions exhibited the cultural value of Ujima, the Swahili word that means “collective work and responsibility” (Karenga, 2008). Audra had her own job and used the term help out her family by not draining the family resources with her own needs and requests. She attempted to be self-sufficient while also helping support her grandmother and aunt’s households when she was living with them.

The construct of “womanist mothering” (Abdullah, 2012) was a defining feature of the gender theme in this case. For Audra, everyday life decisions were shaped by her mothering community, specifically, her mother, grandmother, and aunt. Audra described the ways that she was absorbing the maternal roles of her mothering community (González-Prendes & Thomas, 2009). They modeled a strong ability to provide for the children as both a “mother” and “father.” Each woman was delivering messages to empower Audra to succeed in all aspects of life while also teaching her life lessons that included challenging the notion that future self-sufficiency requires a father to be present. Audra’s mothering community focused on personal and community responsibility as core values. The messages received and revealed by Audra showed consistency with Africentric models of community that are grounded in connections, collectivism, and personal accountability to the community. Thus, Audra’s kinship network continuously modeled a shared struggle for survival, while also the maintenance of deep bonds within the community in the context of the struggle. It seems that Audra was being taught that as African American women become empowered (Vergara-Lopez & Roberts, 2015), they can be an even greater source of support for others.

The empowerment that was being messaged to Audra was not only about her maternal role but also related to her sexual identity. Audra often referenced conflict and feelings around being a “sexualized object” as she was perceived as physically attractive. Audra had awareness of stereotypes of African American girls having high rates of teen pregnancy and she (and her mothers) had discussions about not being the “statistic.” Her mothering community focused on reinforcing personal responsibility and self-respect. While Audra had the intellectual capacity and insight to enact personal responsibility, it did not prevent her from being in situations where she was at risk for sexual assault and dating violence. Thus, she was well aware of her risk and spent a significant portion of treatment on the emotional processing of these factors in the context of her relationships.

The final theme emerged not only on its own, but also embedded within the aforementioned themes: Race/ethnicity. Audra’s awareness of her racial heritage and ethnic identity permeated all aspects of the therapy. Her racial phenotype impacted how her peer relationships were formed and maintained (Ecklund & Johnson, 2007). Discussion about skin tone and natural hairstyles was an important element of the treatment for Audra as the discussions impacted how she interacted with the clinician and even how rapport developed between her and the clinician. Research has shown that the phenotypic makeup of ethnic minority youth is often the initial reason why youth are exposed to specific stereotypes or discrimination (Brittian, 2012). A strong element of the treatment was to normalize her feelings and perceptions around this pattern of social enactment. Through this process, it was evident that Audra’s attempts to cope with this challenge were intertwined into her search for a positive sense of identity (Ecklund & Johnson, 2007). It was evident that she could discuss the challenges with being referred to as “mixed race” (even though she was not) and how it made her feel in relation to her other family members. This dynamic was also evident in a study by Ecklund and Johnson (2007). Audra was also able to identify the ways in which she behaved in order to avoid enacting stereotypes. The depth of the discussions was a key element for the clinician in building her coping skills and integrating elements of the treatment into her cognitive processes. Had the clinician avoided discussions of race and identity, she would have missed the ways in which Audra thinks and feels in the majority of social situations. Subsequently, she would have been less effective in helping Audra apply treatment techniques to other situations outside of the session.

The greatest implication for treatment is the clear necessity for recognizing the existence of intersectionality. Clinicians must reconceptualize their thinking of the constructs of race, class, and gender as interlocking systems of oppression that not only exist within the external environment, but they also create a foundation for the challenges that the African American kinship network is to overcome. The oppression is transmitted intergenerationally through parenting interactions, role definition, and ethnic identity formation. Thus, to provide culturally responsive treatment, a discussion of these interlocking systems and the impact on the individual’s cultural context must occur. Awareness of these issues is only the first step and practicing implementation within an evidence-based treatment is required.

12 Recommendations to Clinicians and Students

Therapy with Audra provided a concrete look into the ways that the cultural context must be integrated into treatment. As the clinician remained true to the tenants of the evidence-based treatment approach, she was able to be flexible and grounded in recognizing the complex layers of need with this particular client. We argue that the layers of complexity can only be unpacked by a clinician who practices with multicultural intentionality. The following recommendations apply to both experienced clinicians and clinicians in training:

Use clinical interviewing tools such as the JIMIS (Jones, 2009) and the Cultural Formulation Interview within the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) to gain foundational cultural understanding as well as to open the lines of communication about cultural factors. Making this intentional effort demonstrates to the client that cultural factors are equally important (even more so than the symptoms) because cultural factors can be both sources of stress as well as sources of strength and resilience.

Obtain a clear understanding of how culture is enacted using models such as the ADDRESSING framework (Hays, 2016) to structure the information that is gained throughout treatment. Using a framework may reduce the likelihood that a clinician will miss essential domains of cultural strength or challenges. As a result, clinicians should listen for key constructs within the framework and seek depth of understanding.

Clinicians should push through any personal discomfort that is due to a desire to be politically correct. Clients can sense the discomfort with their clinicians and those from communities of color are socialized to alleviate that discomfort in cross-cultural interactions. Thus, the personal discomfort in discussing issues of race and culture could actually translate into the client avoiding discussion of issues related to race and culture. Clinicians should recognize that seeking understanding of cultural factors often lead to strengths that can be integrated as part of the intervention.

When treatment seems stagnant or rapport seems strained, seek consultation from cultural broker. Sometimes the lack of rapport is not obvious. For example, a client may show inconsistent attendance (including “no shows”) or make statements that indicate a desire to comply with treatment goals while all nonverbal cues and actual behaviors reflect the opposite. When this pattern of interaction in treatment is present, the treatment rarely makes it past a superficial level.

Clinicians should stay constantly aware of the existence of intersectionality with clients of color. Clinicians should never address each element (race or ethnicity, class, gender) in isolation. Remember that these variables are interrelated and the treatment must focus on the relationships among the elements. As we saw with Audra, race and ethnic factors permeated the other themes, so the clinician had to work with the intersection of race (phenotype) and gender (female roles) and development (ethnic identity) simultaneously. Audra was experiencing ongoing oppression in each of these cultural areas so it was important that they were embedded in treatment. Thus, it is critical to recognize that systems of oppression are maintained when they are not acknowledged.

Footnotes

Acknowledgements

The authors thank Hao Jan Luh, Juhn Tse, and Kristin Kawena Begay for their assistance in analyzing the transcripts for this study.

Authors’ Note

Identifying details (including client names and city of origin) have been modified to protect the identity of the client and her family.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the University of Washington, Royalty Research Fund.

Author Biographies

Julia C. Zigarelli, EdS, NCSP, is a doctoral candidate in the School Psychology Program at the University of Washington. She is a Nationally Certified School psychologist who is completing predoctoral internship at the University of New Mexico Health Sciences Center in Albuquerque, NM.

Janine M. Jones, PhD, NCSP, is an associate professor in the School Psychology program at the University of Washington. Her primary focus of research is on culturally responsive mental health interventions with children and adolescents. She edited The psychology of multiculturalism in the schools: A primer for practice, training, and research.

Cinthia I. Palomino is a PhD student in the School Psychology Program at the University of Washington. Her research interests include academic and behavior interventions for English language learners and low-income Latino students. Specifically, she is interested in researching the effects of self-regulation in economically disadvantaged Latino preschool children’s behavior adjustment and academic performance.

Reiko Kawamura is a PhD student at the Center for Social and Cultural Psychology of the University of Leuven in Belgium. Her research interest includes cultural differences in emotion dynamics of mother–adolescent dyads. She investigates conflict situations to analyze the emotion patterns and the functions of emotions during these events.

References

Abdullah

(2012). Womanist mothering: Loving and raising the revolution. The Western Journal of Black Studies, 26, 57-67.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Atkinson

D. R.

Wampold

B. E.

Lowe

S. M.

Matthews

Ahn

H. N.

(1998). Asian American preferences for counselor characteristics: Application of the Bradley-Terry-Luce model to paired comparison data. The Counseling Psychologist, 26(1), 101-123.

Benish

S. G.

Quintana

Wampold

B. E.

(2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology, 58, 279-289. Retrieved from https://dx-doi-org.web.bisu.edu.cn/10.1037/a0023626

Brittian

A. S.

(2012). Understanding African American adolescents’ identity development: A relational developmental systems perspective. Journal of Black Psychology, 38, 172-200. doi:10.1177/0095798411414570

Cabassa

L. J.

Baumann

A. A.

(2013). A two-way street: Bridging implementation science and cultural adaptations of mental health treatments. Implementation Science, 8(1), 1-14. doi:10.1186/1748-5908-8-90

Cabral

R. R.

Smith

T. B.

(2011). Racial/ethnic matching of clients and therapists in mental health services: A meta-analytic review of preferences, perceptions, and outcomes. Journal of Counseling Psychology, 58, 537-554. doi:10.1037/a0025266

Cheng

P. H.

Carter

R. T.

Lee

D. Y.

(2015). The relationship between racial identity status attitudes and acculturation among Chinese and Korean Americans: A criterion profile analysis. Journal of Multicultural Counseling and Development, 43, 97-108.

Coard

S. I.

Wallace

S. A.

Stevenson

H. C.

Brotman

L. M.

(2004). Towards culturally relevant preventive interventions: The consideration of racial socialization in parent training with African American families. Journal of Child and Family Studies, 13, 277-293. Retrieved from http://doi.org/10.1023/B:JCFS.0000022035.07171.f8

10.

Dedoose Version 6.1.18, web application for managing, analyzing, and presenting qualitative and mixed method research data. (2015). Los Angeles, CA: SocioCultural Research Consultants. Available from www.dedoose.com

11.

Ecklund

Johnson

W. B.

(2007). The impact of a culture-sensitive intake assessment on the treatment of a depressed biracial child. Clinical Case Studies, 6, 468-482. Retrieved from http://doi.org/10.1177/1534650106296939

12.

González-Prendes

Hindo

Pardo

(2011). Cultural values integration in cognitive-behavioral therapy for a Latino with depression. Clinical Case Studies, 10, 376-394. Retrieved from http://doi.org/10.1177/1534650111427075

13.

González-Prendes

Thomas

S. A.

(2009). Culturally sensitive treatment of anger in African American women: A single case study. Clinical Case Studies, 8, 383-402. Retrieved from http://doi.org/10.1177/1534650109345004

14.

Hartman

(1995). Diagrammatic assessment of family relationships. Families in Society, 76, 111-122.

15.

Hays

P. A.

(2009). Integrating evidence-based practice, cognitive–behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psychology: Research and Practice, 40, 354-360. Retrieved from http://doi.org/10.1037/a0016250

16.

Hays

P. A.

(2016). Addressing cultural complexities in practice: A framework for clinicians and counselors (3rd ed.). Washington, DC: American Psychological Association.

17.

Hill

R. B.

(1999). The strengths of African American families: Twenty-five years later. Lanham, MD: University Press.

18.

Hinton

D. E.

Hofmann

S. G.

Rivera

Otto

M. W.

Pollack

M. H.

(2011). Culturally adapted CBT (CA-CBT) for Latino women with treatment-resistant PTSD: A pilot study comparing CA-CBT to applied muscle relaxation. Behavior Research and Therapy, 49, 275-280. doi:10.1016/j.brat.2011.01.005

19.

Hofmann

S. G.

Asnaani

Vonk

I. J. J.

Sawyer

A. T.

Fang

(2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36, 427-440. Retrieved from http://doi.org/10.1007/s10608-012-9476-1

20.

Iwamoto

D. K.

Negi

N. J.

Partiali

R. N.

Creswell

J. W.

(2013). The racial and ethnic identity formation process of second-generation Asian Indian Americans: A phenomenological study. Journal of Multicultural Counseling and Development, 41, 224-239.

21.

Jones

J. M.

(2007). Exposure to chronic community violence: Resilience in African American children. Journal of Black Psychology, 33, 125-149. doi:10.1177/0095798407299511

22.

Jones

J. M.

(2009). Counseling with multicultural intentionality: The process of counseling and integrating client cultural variables. In Jones

J. M.

(Ed.), The psychology of multiculturalism in the schools: A primer for practice, training, and research (pp. 191-213). Bethesda, MD: National Association of School Psychologists.

23.

Jones

J. M.

Begay

K. K.

Nakagawa

Cevasco

Sit

(2015). Multicultural counseling competence training: Adding value with multicultural consultation. Journal of Educational & Psychological Consultation, 25, 1-26. doi:10.1080/10474412.2015.1012671

24.

Karenga

(2008). Kwanzaa: A celebration of family, community, and culture (2nd ed.). Los Angeles, CA: University of Sankore Press.

25.

López

C. M.

Shealy

K. M.

Rheingold

A. A.

(2014). Empirically supported trauma treatment for an adult Latino man diagnosed with PTSD: Overcoming barriers to engagement. Clinical Case Studies, 13, 436-452. Retrieved from http://doi.org/10.1177/1534650114521282

26.

Miles

M. B.

Huberman

M. A.

Saldaña

J. M.

State

(2014). Qualitative data analysis: A methods sourcebook (3rd ed.). Thousand Oaks, CA: Sage.

27.

Piña-Watson

López

Ojeda

Rodriguez

K. M.

(2015). Cultural and cognitive predictors of academic motivation among Mexican American adolescents: Caution against discounting the impact of cultural processes. Journal of Multicultural Counseling and Development, 43, 109-121.

28.

Reynolds

C. R.

Kamphaus

R. W.

(2006). BASC-2: Behavior Assessment System for Children, Second Edition. Upper Saddle River, NJ: Pearson Education.

29.

Reynolds

W. M.

(2002). Reynolds Adolescent Depression Scale: Professional manual (2nd ed.). Odessa, FL: Psychological Assessment Resources.

30.

Saldaña

(2016). The coding manual for qualitative researchers (3rd ed.). Los Angeles, CA: Sage.

31.

Sondhi

Gulgulia

Shriharsh

(2013). Cognitive-behavioral therapy for an Indian adolescent with depression: A clinical case study. Clinical Case Studies, 12, 157-173. Retrieved from http://doi.org/10.1177/1534650112470741

32.

Sue

D. W.

Arredondo

McDavis

J. R.

(1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20, 64-88.

33.

Sue

D. W.

Sue

(2016). Counseling the culturally different: Theory and practice (7th ed.). Hoboken, NJ: John Wiley.

34.

Tynes

B. M.

Umana-Taylor

A. J.

Rose

C. A.

Lin

Anderson

C. J.

(2012). Online racial discrimination and the protective function of ethnic identity and self-esteem for African American adolescents. Developmental Psychology, 48, 343-355. doi:10.1037/a0027032

35.

Vergara-Lopez

Roberts

J. E.

(2015). An application of behavioral activation therapy for major depressive disorder in the context of complicated grief, low social-economic status, and ethnic minority status. Clinical Case Studies, 14, 247-261. Retrieved from http://doi.org/10.1177/1534650115593847

36.

Wang

Kim

B. S.

(2010). Therapist multicultural competence, Asian American participants’ cultural values, and counseling process. Journal of Counseling Psychology, 57, 394-401. Retrieved from http://doi.org/10.1037/a0020359

37.

Weiss

B. J.

Singh

J. S.

Hope

D. A.

(2011). Cognitive-behavioral therapy for immigrants presenting with social anxiety disorder: Two case studies. Clinical Case Studies, 10, 324-342. Retrieved from http://doi.org/10.1177/1534650111420706