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Cultural Adaptation of Psychological Trauma Treatment for Children
LETTERS TO THE EDITOR
CULTURAL ADAPTATION OF PSYCHOLOGICAL TRAUMA TREATMENT FOR CHILDREN To the Editor: Providing culturally appropriate intervention for youths of diverse communities is a challenge. Ngo et al.1 propose an illustration of the cultural adaptation of a school-based cognitive behavioral intervention for trauma. They argue that the cultural adaptation is a process of group-specific ‘‘packaging,’’ which does not alter the core components of the cognitive behavioral therapy but can significantly improve effectiveness. According to them, this indicates that it is possible to strike a balance between fidelity to evidence-based treatment and culturally informed care. This is a very valuable proposition because it sensitizes clinicians and researchers to the need to tailor evidence-based treatment to the specificity of the communities they serve. The authors also suggest a useful community consultation process to support the adaptation procedure. However, ascribing the effectiveness of culturally adapted intervention to the core components of cognitive-behavioral therapy (CBT) raises important ethical and scientific questions. First, minimizing or ignoring the potential therapeutic value of the cultural elements that are incorporated in the intervention and considering them as active ingredients only because they represent forms of cognitive intervention can be seen as a form of ethnocentrism.2 The authors mention, as examples, burning sweet grass during relaxation exercises with Native Americans; prayer, meditation, and forgiveness rituals in faith-based schools as forms of social problem solving; or writing a song, a poem, or a novel as forms of trauma narrative. These are all fascinating avenues of intervention; they do not only mobilize cognition, but they are also communal, artistic, and spiritual processes that have cognitive aspects but certainly cannot be reduced to conventional cognitive therapy. Of course, there are important convergences between some of the great healing traditions in humanity and contemporary psychotherapies.3 For example, there are close parallels and explicit borrowing between CBT and Buddhist mindfulness meditation,4 Although recognizing these convergences is important, amalgamating everything under a western manual-based approach to CBT can be seen as reductionistic and risks leaving out crucial elements including the larger context and
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meaning of interventions that may contribute to their effectiveness.5 Furthermore, in discussing the psychoeducational components of the intervention, the authors suggest using local cultural terminology or idioms of distress. They give the example of ‘‘nervios’’ or ‘‘mal de ojo,’’ which are terms commonly used in Latino communities. Nervios refers both to nonspecific somatic and psychological symptoms of ‘‘nervousness’’ and to an etiology (‘‘nerves’’), which is often not elaborated.6 Mal de ojo refers more explicitly to a causal attribution or explanatory model that explains a wide array of physical and psychological symptoms. Even if there are links between these constructs and posttraumatic stress disorder, they cover a much wider territory, and their use as a proxy for a DSM trauma construct in a psychoeducation intervention may be problematic for a clinician who is not very familiar with their local connotations. Finally, adding cultural practices to core CBT elements without considering the specific effectiveness of the former introduces an important bias in the evidence-based conclusion because it attributes effectiveness to the manual-based intervention without questioning the role of other potentially active ingredients. Meta-analyses of evidence based treatments suggest that, although trauma-focused CBT have been widely researched and found to be effective, other specific and nonspecific psychological trauma treatment for children and youths are promising and may be proven effective if adequately designed studies are realized.7 The cultural adaptation of manual-based interventions should be encouraged, but it must be supported by a careful evaluation of the active role of the added components. Cultural adaptation may thus be seen as the merger of different strong therapeutic traditions, which potentiate each other, rather than as simply a cosmetic packaging and marketing of mainstream knowledge. Ce´cile Rousseau, M.D., M.Sc. Laurence Kirmayer, M.D. McGill University, Montreal Quebec, Canada Disclosure: The authors report no conflicts of interest. 1. Ngo V, Langley A, Kataoka SH, Nadeem E, Escudero P, Stein BD. Providing evidence-based practice to ethnically diverse youths: examples
J. AM. A CAD. C HILD AD OLESC. PSYCHIATRY, 48: 9, SE PTEMBER 2009
LETTERS TO THE EDITOR
2. 3. 4.
5. 6. 7.
from the cognitive behavioral intervention for trauma in schools (CBITS) program. J Am Acad Child Adolesc Psychiatry. 2008;47:858Y862. Calabrese JD. Clinical paradigm clashes: ethnocentric and political barriers to Native American efforts at self-healing. Ethos. 2008;36:334Y353. Kirmaycr LJ. The cultural diversity of healing: meaning, metaphor and mechanism. Br Med Bull. 2004;69:33Y48. Hinton DE, Chhean D, Pich V, Safren SA, Hofmann SO, Pollack MH. A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment resistant PTSD and panic attacks: a cross-over design. J Trauma Stress. 2005;18:617Y629. Rousseau C, Guzder J. School-based prevention programs for refugee children. Child Adolesc Psychiatr Clin N Am. 2008;17:533Y549. Ouamaccia PJ, Lewis-Fernandez R, Marano MR. Toward a Puerto Rican popular nosology: nervios and ataque de nervios. Cult Med Psychiatry. 2003;27:339Y366. National Collaborating Centre for Mental Health, and Royal College of Psychiatrists’ Research Unit. Post-Traumatic Stress Disorder. The Management of PTSD in Adults and Children in Primary and Secondary Care (Vol. National Clinical Practice Guideline Number 26). London: Gaskell and the British Psychological Society; 2005.
DOI: 10.1097/CHI.0b013e3181b21669
Dr. Ngo et al. reply: There is much to be learned in terms of the therapeutic value of cultural elements of clinical practice. We agree that we simply do not yet know which components of many treatments are the ‘‘active ingredients’’ and that more research in this area is greatly needed. Fortunately, there is growing evidence that cognitive-behavioral therapy (CBT) is effective for a range of disorders (posttraumatic stress disorder, anxiety disorders, and depression) in adults and youths and has been found to be effective for diverse communities, irrespective of adaptations.1Y2 However, there are frequent barriers to accessing these effective treatments, especially for some low socioeconomic status and/or ethnic minority communities. In thinking about how to best serve diverse communities, some researchers have stressed the importance of testing known psychosocial treatments in these communities,1Y3 whereas others have advocated for evaluating adaptations of evidence-based treatments (EBTs) to match the parameters of specific service systems or communities.4 In the case of Cognitive Behavioral Intervention for Trauma in Schools (CBITS), we presented a blended model, in which a community participatory partnership was developed between schools, treatment experts, and researchers, to address the needs of diverse ethnic minority students. This partnership informed all stages of CBITS implementation, from how to operationalize the core elements of CBT, to engagement with local communities, to addressing contextual issues unique to schools and ethnic minority communities. It is clear that individuals from various cultural groups each have unique factors that need to be taken into consideration when providing any form of psychotherapy and that EBTs developed based on work with mainstream samples may not take into account the variation that exists in customs, values, child-rearing traditions, parenting behavior, coping behavior,
J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTE MBER 2009
stressors, and resources associated with different cultural groups. Concerns have been raised that these differences, if not taken into consideration, may negatively have an impact on engagement in the therapy process as well as outcomes for ethnic minorities.4 However, in the attempt to make treatments more culturally responsive to ethnic minorities, it is important that adaptations do not compromise the core features of the interventions and, therefore, their effectiveness.3 Lau3 offers a useful road map for cultural adaptations of EBTs, wherein adaptation efforts target EBTs that have poor fit with a particular cultural group and are guided by research findings related to specific differences that may have an impact on engagement and clinical outcomes. Research has shown that CBT models, when delivered in a culturally appropriate manner, have been found to be effective with ethnic minorities.1,2 Thus, in our trainings, we emphasize the importance of maintaining fidelity and quality of the core CBT techniques, such as teaching of coping skills, cognitive restructuring, and exposure to trauma reminders. However, as with all clients, these skills must be framed around cultural beliefs, values, and practices that are relevant and meaningful to the individual or group of individuals one is working with. Finding common language to connect with patients is important with every client. In the CBITS program, it was important to partner with community experts so that the cognitive behavioral intervention techniques could be used with language and examples that facilitated their acceptability and relevance and increased both engagement with and clinical salience of these skills. It is certainly possible that these cultural practices and rituals may, by themselves, be agents of change in the therapeutic process, and we agree that more research is needed to study the effectiveness of these cultural elements. However, in the absence of this empirical base, it is important that EBTs not be denied to ethnic minority patients, particularly when there is growing evidence that supports the use of these interventions for ethnic minorities in the United States1,2 as well as diverse communities abroad.5 Victoria Ngo, Ph.D. RAND Corporation Santa Barbara, CA Audra Langley, Ph.D. Sheryl H. Kataoka, M.D., M.S.H.S. UCLA Semel Institute University of California Los Angeles Erum Nadeem, Ph.D. New York State Psychiatric Institute Columbia University New York
WWW.JAACAP.COM
955
CULTURAL ADAPTATION OF PSYCHOLOGICAL TRAUMA TREATMENT FOR CHILDREN To the Editor: Providing culturally appropriate intervention for youths of diverse communities is a challenge. Ngo et al.1 propose an illustration of the cultural adaptation of a school-based cognitive behavioral intervention for trauma. They argue that the cultural adaptation is a process of group-specific ‘‘packaging,’’ which does not alter the core components of the cognitive behavioral therapy but can significantly improve effectiveness. According to them, this indicates that it is possible to strike a balance between fidelity to evidence-based treatment and culturally informed care. This is a very valuable proposition because it sensitizes clinicians and researchers to the need to tailor evidence-based treatment to the specificity of the communities they serve. The authors also suggest a useful community consultation process to support the adaptation procedure. However, ascribing the effectiveness of culturally adapted intervention to the core components of cognitive-behavioral therapy (CBT) raises important ethical and scientific questions. First, minimizing or ignoring the potential therapeutic value of the cultural elements that are incorporated in the intervention and considering them as active ingredients only because they represent forms of cognitive intervention can be seen as a form of ethnocentrism.2 The authors mention, as examples, burning sweet grass during relaxation exercises with Native Americans; prayer, meditation, and forgiveness rituals in faith-based schools as forms of social problem solving; or writing a song, a poem, or a novel as forms of trauma narrative. These are all fascinating avenues of intervention; they do not only mobilize cognition, but they are also communal, artistic, and spiritual processes that have cognitive aspects but certainly cannot be reduced to conventional cognitive therapy. Of course, there are important convergences between some of the great healing traditions in humanity and contemporary psychotherapies.3 For example, there are close parallels and explicit borrowing between CBT and Buddhist mindfulness meditation,4 Although recognizing these convergences is important, amalgamating everything under a western manual-based approach to CBT can be seen as reductionistic and risks leaving out crucial elements including the larger context and
954
WWW.JAACAP.COM
meaning of interventions that may contribute to their effectiveness.5 Furthermore, in discussing the psychoeducational components of the intervention, the authors suggest using local cultural terminology or idioms of distress. They give the example of ‘‘nervios’’ or ‘‘mal de ojo,’’ which are terms commonly used in Latino communities. Nervios refers both to nonspecific somatic and psychological symptoms of ‘‘nervousness’’ and to an etiology (‘‘nerves’’), which is often not elaborated.6 Mal de ojo refers more explicitly to a causal attribution or explanatory model that explains a wide array of physical and psychological symptoms. Even if there are links between these constructs and posttraumatic stress disorder, they cover a much wider territory, and their use as a proxy for a DSM trauma construct in a psychoeducation intervention may be problematic for a clinician who is not very familiar with their local connotations. Finally, adding cultural practices to core CBT elements without considering the specific effectiveness of the former introduces an important bias in the evidence-based conclusion because it attributes effectiveness to the manual-based intervention without questioning the role of other potentially active ingredients. Meta-analyses of evidence based treatments suggest that, although trauma-focused CBT have been widely researched and found to be effective, other specific and nonspecific psychological trauma treatment for children and youths are promising and may be proven effective if adequately designed studies are realized.7 The cultural adaptation of manual-based interventions should be encouraged, but it must be supported by a careful evaluation of the active role of the added components. Cultural adaptation may thus be seen as the merger of different strong therapeutic traditions, which potentiate each other, rather than as simply a cosmetic packaging and marketing of mainstream knowledge. Ce´cile Rousseau, M.D., M.Sc. Laurence Kirmayer, M.D. McGill University, Montreal Quebec, Canada Disclosure: The authors report no conflicts of interest. 1. Ngo V, Langley A, Kataoka SH, Nadeem E, Escudero P, Stein BD. Providing evidence-based practice to ethnically diverse youths: examples
J. AM. A CAD. C HILD AD OLESC. PSYCHIATRY, 48: 9, SE PTEMBER 2009
LETTERS TO THE EDITOR
2. 3. 4.
5. 6. 7.
from the cognitive behavioral intervention for trauma in schools (CBITS) program. J Am Acad Child Adolesc Psychiatry. 2008;47:858Y862. Calabrese JD. Clinical paradigm clashes: ethnocentric and political barriers to Native American efforts at self-healing. Ethos. 2008;36:334Y353. Kirmaycr LJ. The cultural diversity of healing: meaning, metaphor and mechanism. Br Med Bull. 2004;69:33Y48. Hinton DE, Chhean D, Pich V, Safren SA, Hofmann SO, Pollack MH. A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment resistant PTSD and panic attacks: a cross-over design. J Trauma Stress. 2005;18:617Y629. Rousseau C, Guzder J. School-based prevention programs for refugee children. Child Adolesc Psychiatr Clin N Am. 2008;17:533Y549. Ouamaccia PJ, Lewis-Fernandez R, Marano MR. Toward a Puerto Rican popular nosology: nervios and ataque de nervios. Cult Med Psychiatry. 2003;27:339Y366. National Collaborating Centre for Mental Health, and Royal College of Psychiatrists’ Research Unit. Post-Traumatic Stress Disorder. The Management of PTSD in Adults and Children in Primary and Secondary Care (Vol. National Clinical Practice Guideline Number 26). London: Gaskell and the British Psychological Society; 2005.
DOI: 10.1097/CHI.0b013e3181b21669
Dr. Ngo et al. reply: There is much to be learned in terms of the therapeutic value of cultural elements of clinical practice. We agree that we simply do not yet know which components of many treatments are the ‘‘active ingredients’’ and that more research in this area is greatly needed. Fortunately, there is growing evidence that cognitive-behavioral therapy (CBT) is effective for a range of disorders (posttraumatic stress disorder, anxiety disorders, and depression) in adults and youths and has been found to be effective for diverse communities, irrespective of adaptations.1Y2 However, there are frequent barriers to accessing these effective treatments, especially for some low socioeconomic status and/or ethnic minority communities. In thinking about how to best serve diverse communities, some researchers have stressed the importance of testing known psychosocial treatments in these communities,1Y3 whereas others have advocated for evaluating adaptations of evidence-based treatments (EBTs) to match the parameters of specific service systems or communities.4 In the case of Cognitive Behavioral Intervention for Trauma in Schools (CBITS), we presented a blended model, in which a community participatory partnership was developed between schools, treatment experts, and researchers, to address the needs of diverse ethnic minority students. This partnership informed all stages of CBITS implementation, from how to operationalize the core elements of CBT, to engagement with local communities, to addressing contextual issues unique to schools and ethnic minority communities. It is clear that individuals from various cultural groups each have unique factors that need to be taken into consideration when providing any form of psychotherapy and that EBTs developed based on work with mainstream samples may not take into account the variation that exists in customs, values, child-rearing traditions, parenting behavior, coping behavior,
J. AM . ACAD. CHILD ADOLESC. PSYCH IAT RY, 48:9, SEPTE MBER 2009
stressors, and resources associated with different cultural groups. Concerns have been raised that these differences, if not taken into consideration, may negatively have an impact on engagement in the therapy process as well as outcomes for ethnic minorities.4 However, in the attempt to make treatments more culturally responsive to ethnic minorities, it is important that adaptations do not compromise the core features of the interventions and, therefore, their effectiveness.3 Lau3 offers a useful road map for cultural adaptations of EBTs, wherein adaptation efforts target EBTs that have poor fit with a particular cultural group and are guided by research findings related to specific differences that may have an impact on engagement and clinical outcomes. Research has shown that CBT models, when delivered in a culturally appropriate manner, have been found to be effective with ethnic minorities.1,2 Thus, in our trainings, we emphasize the importance of maintaining fidelity and quality of the core CBT techniques, such as teaching of coping skills, cognitive restructuring, and exposure to trauma reminders. However, as with all clients, these skills must be framed around cultural beliefs, values, and practices that are relevant and meaningful to the individual or group of individuals one is working with. Finding common language to connect with patients is important with every client. In the CBITS program, it was important to partner with community experts so that the cognitive behavioral intervention techniques could be used with language and examples that facilitated their acceptability and relevance and increased both engagement with and clinical salience of these skills. It is certainly possible that these cultural practices and rituals may, by themselves, be agents of change in the therapeutic process, and we agree that more research is needed to study the effectiveness of these cultural elements. However, in the absence of this empirical base, it is important that EBTs not be denied to ethnic minority patients, particularly when there is growing evidence that supports the use of these interventions for ethnic minorities in the United States1,2 as well as diverse communities abroad.5 Victoria Ngo, Ph.D. RAND Corporation Santa Barbara, CA Audra Langley, Ph.D. Sheryl H. Kataoka, M.D., M.S.H.S. UCLA Semel Institute University of California Los Angeles Erum Nadeem, Ph.D. New York State Psychiatric Institute Columbia University New York
WWW.JAACAP.COM
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