Two Key Studies of the Role of Culture in Treatment of Disorders (SL IB Psychology)

Aneesah Nadir and David Hodge

Aim: To investigate the extent to which Western-style counselling practices are appropriate for other cultures.

Procedure: 

• A review of research on the topic which looked at four commonly-used therapeutic approaches to the treatment of a range of mental illnesses such as MDD and phobias 
• The four different types of counselling therapies included in the review were:
  • Psychoanalytic therapy
  • Group therapy
  • Strength-based therapy
  • Cognitive Behavioural therapy (CBT)

• The researchers were interested in investigating the provision of what they term ‘culturally competent services to Muslims’ i.e. they were looking for evidence of therapies that are most aligned to a Muslim outlook and cultural perspective and which are most congruent with Islamic values

Results:  

• Two therapeutic models/treatments were identified by the researchers as problematic for Muslim clients:
• Psychoanalytic approaches - the emphasis on individual introspection is at odds with the importance in Islamic culture of community i.e. rather than looking inwards to analyse themselves, Muslims tend to look outwards, grounding their identity in religious teachings, culture and family
• Group therapy – some Muslims may feel uncomfortable sharing personal details or disclosures in a group setting, particularly if the group included both males and females who are not related
• Two forms of therapy were identified as being more suitable to treating Muslims:
• Strength-based approach – in this approach, strengths are identified, derived from a client’s faith, family, culture and community: such values are more congruent with Islamic ideals
• CBT the underlying principles of CBT are congruent with Islamic values e.g. focusing on solutions, using a ‘here and now’ approach
• CBT, however, could be modified to substitute traditional self-statements (e.g. ‘I feel in control of my thoughts’) with statements linked to Mulsims’ spiritual traditions
• This approach (cited in the above bullet point) has been successful in Taoist, Christian and Muslim cultural settings as it draws directly from articles of faith within that culture 
• The researchers state that this adaptation of CBT in order to align it with Muslim values is necessary, as from an Islamic perspective, the ultimate success of an individual’s efforts is dependent upon God

Conclusion: Adaptations and modifications to existing treatments such as CBT should help to align these treatments with the client’s values and to ensure that treatment outcome is positive. 

Evaluation of Hodge and Nadir (2008)

Strengths

• This research has good application to an array of settings e.g. schools, hospitals, community health hubs which could be of great benefit given that most communities in the 21st century are multicultural
• The findings support the idea that CBT in particular is a flexible treatment which can be modified to suit a range of different needs and perspectives which may help to move therapy away from ‘blaming’ the client (which psychotherapy has a tendency to do)

Weaknesses

• The findings are a little generalised: the modifications suggested may not suit all Muslim clients, there are likely to be individual differences involved in the success of the suggested strategy as well as variations in Islamic beliefs so we should not consider all Muslims as homogenous
• A review analyses secondary data which may not be as reliable as primary data i.e. the researchers had no control over how the data was collected which could reduce the reliability of the findings

Key terms: Review  Psychoanalytic therapy  Strength-based therapy

The traditional model of therapy may not be appropriate for all cultures

Key study two: Hinton et al. (2005) 

Aim: 

• To investigate the therapeutic efficacy of culturally adapted CBT for Cambodian refugees with treatment-resistant PTSD and panic attacks
• To investigate the extent to which different treatment methods should be prescribed for refugees from different cultures
• Refugees often have severe PTSD and a range of anxiety disorders resulting from the  traumas they have endured 

Participants: 

• 40 participants who had survived the Cambodian genocide between 1975-1979 and had fled to the USA, having no knowledge of American culture or the English language
• The participants were from rural, fairly isolated and non-industrialised villages so an extra stressor for them was having to adapt to urban environments
• The participants had undergone various types of therapy for whom all other treatments had failed (this is known as ‘treatment-resistant’): they suffered from extreme panic attacks
• The CBT was designed by the therapists to be more in line with Cambodian culture i.e. with more emphasis on collectivism and traditional values than on individualism

Procedure: 

• The participants were randomly allocated to one of two conditions of the independent variable:
• Initial treatment (IT) condition - this refers to the first treatment given to a patient (it may be followed by other treatments if the initial treatment fails to be effective)
• Delayed treatment (DT) condition - this refers to a delay in receiving the treatment i.e. the participants were on a ‘waiting list’ for the CBT
• There were 20 participants per condition 
• All participants continued supportive psychotherapy, which consisted of a meeting with a social worker every 2 weeks, and all of them continued to take their prescribed medication: an SSRI (to treat their  MDD) and benzodiazepine clonazepam (to treat their panic attacks)
• Both groups were measured at the following time points:
• At baseline, before they had started CBT
• When the IT group had completed their 12 sessions of CBT
• When the DT group had completed their 12 sessions of CBT
• 12 weeks after each group had completed their therapy
• Both groups’ symptoms were measured by a bilingual Cambodian researcher who did not know which treatment condition the participants were in, using standardised tests for PTSD and general anxiety disorder (GAD), panic attacks
• The CBT was modified culturally to be appropriate to the Cambodian participants 
• A lot of the Cambodian’s PTSD symptoms were somatic (e.g. neck pain, dizziness), so the CBT was adapted to include Sensory Reprocessing Therapy (SRT), focusing on sensations and decreasing stress through muscle relaxation and breathing training
• The adaptation of the CBT also included culturally sensitive features such as asking the patients to visualise a lotus blossom spinning in the wind which encompasses Asian values of flexibility

Results:

• The participants in the IT condition improved significantly in comparison to those in the DT condition showing large effect sizes for all measures of PTSD e.g. 3.78 on the Anxiety Sensitivity Index (for guidance 0.8 is considered a large effect size)
• By the second assessment, 12 of the IT patients no longer met the diagnostic criteria for PTSD  and 11 of these patients also no longer met GAD criteria
• The IT patients also found that their somatic symptoms had decreased
• The DT patients all met the criteria for both PTSD and GAD i.e. their symptoms remained unchanged
• At the third assessment i.e. once all of the patients had experienced the culturally-adapted CBT, 10 of the DT patients no longer met the PTSD criteria and 9 of them no longer met the GAD criteria

Conclusion: 

• Culturally adapted CBT focusing on PTSD and panic attacks may be effective in reducing symptoms and distress for a range of anxiety disorders
• Receiving CBT as the initial treatment appears to result in the best outcomes for PTSD patients
  
  

Evaluation of Hinton et al. (2005) 

Strengths

• Using a culturally-adapted form of CBT gives this study external validity as it could be used as a template for other culture-specific treatments for patients with anxiety disorders
• The use of the three time-point measurements means that the study has good internal validity as the researchers were able to assess the efficacy of culturally-adapted CBT across time

Weaknesses

• The participants who were allocated to the waiting list may have suffered from not receiving CBT as initial treatment which does give rise to some ethical considerations in terms of protection of participants
• The participants had endured a very particular type of extreme trauma so it is not known to what extent culturally-adapted CBT could be used for other disorders