The Application Of Cognitive Behavior Therapy On Asian Americans

Running head:

The Application of Cognitive Behavior Therapy on Asian Americans

The Application of Cognitive Behavior Therapy on Asian Americans Gregory Cordes General Psychology PSY7540 Multi-Cultural Perspectives in Human Behavior Spring 2008 [email protected]

Abstract

In this paper, I will identify some of the distinctive qualities of Asian American culture, describe and explain the theoretical underpinnings and application of cognitive behavioral therapy as well as its range of uses, and then integrate the culture into the therapy and show the current research on that application. The Application of Cognitive Behavior Therapy on Asian Americans Introduction Asian Americans Asian Americans distinguish themselves as culturally different from the mainstream because they hold a collectivist orientation (Sue & Sue, 2003). Asians put emphasis on family, individual needs come second. Asian families expect children to be obedient, not to dishonor the family, and strive to achieve the goals of the family. Chinese-Americans instill the importance of calmness and politeness in their children. Families of Adolescent Asian Americans expect them to respect, support, and assist their families even in the face of Western adolescent independence, and autonomy. The parenting style of Asian Americans tends to be different than mainstream America (Sue & Sue, 2003). The structure of Asian American families is patriarchly and hierarchically, older individuals in males occupy higher status (Sue & Sue, 2003). Asian Americans expect their children to defer to adults, while communication flows from parent to child. Asian American parents rely on directive and authoritarian parenting styles in contrast to Euro Americans. Asian Americans believe lack of discipline to be the source in behavioral problems of children. There are some differences in parenting style within the Asian American community. The most egalitarian relationships tend to occur in Filipino and Japanese American families. In contrast, Chinese and Korean American parents take a more authoritarian approach and there are some differences in terms of emotionality between Asian Americans and Euro Americans (Sue & Sue, 2003). Asian Americans discourage strong public emotional displays that they consider an indication of loss of control or immaturity (Sue & Sue, 2003). Even within the family, emotional displays are discouraged. This holds true especially for older children. Parents may use guilt and shame to train and control their children. Family members show concern and care by serving the needs of their relatives. Fathers are authoritative, suppressed emotional demonstrations, and are not directly involved in child rearing. He is the “breadwinner”. Because fathers are not directly involved in child-rearing, mothers play an intermediary role in communication between father and children. Asian Americans expect mothers to care

for the emotional needs of the children. Mothers are less nurturing but more responsive to their children than Euro American mothers, and use more physical and verbal punishments. Academics play an important role in Asian American culture (Sue & Sue, 2003). Asian Americans believe the product of good upbringing is a successful career achieve through academic performance of their children (Sue & Sue, 2003). For this reason, Asian American children perform better academically than Euro Americans (Sue & Sue, 2003). For example, Asian Americans perform better on mathematics tests than both Euro Americans and African-Americans according to the Bell Curve (Herrnstein & Murray, 1996). While the book remains controversial, given the emphasis on academics and the universal nature of mathematics this seems a likely conclusion - after all, in any culture 1 + 1 = 2. Asian American children devote twice the time Euro American children on academics (Sue & Sue, 2003). As a result of this emphasis on academics, many Asian American children fear academic failure. In addition, Asian American adolescence or at greater risk of feeling depressed, anxious, lack of praise, and isolated. In many cases, Asian-American parents picked a career goal for their children typically in the hard sciences or in the technical fields. Deviating from these career choices or academic failure can be a source of conflict between family members. Asian Americans in contrast to Euro Americans consider body and mind inseparable (Sue & Sue, 2003). When experiencing emotional or psychological stress, Asian Americans frequently complain about physical conditions (Sue & Sue, 2003). They see a connection between physical illness and psychological pain. This can occur even with psychotic patients. Asian Americans also suffer from the products of discrimination and racism (Sue & Sue, 2003). Asian Americans report higher rates of workplace discrimination as opposed to Caucasians (Sue & Sue, 2003). For Southeast Asian refugees, this translates into high incidence of depression (Sue & Sue, 2003). In addition, Asian Americans are often stereotyped. Two of the most common are all Asian Americans are pretty much the same, and all Asian Americans are foreign-born. In fact, half are born in the United States (Anonymous, 2005). One of the reasons for this stereotyping is Euro Americans cannot physically identify different Asian Americans, but an Asian American is able to do this (Bascara, C., personal communication, 2005). In addition to stereotyping, Asian American families may suffer parent and child acculturation conflicts (Sue & Sue, 2003). Asian-American parents want their children to maintain their Asian traditions, attitudes, and values (Sue & Sue, 2003). On the other hand, in an effort to fit in, many Asian American children want to discard those values, attitudes, and traditions in favor of Western standards. These acculturation differences can result in conflict, miscommunication, and misunderstandings. Identity issues present another hurdle in the Asian American experience (Sue & Sue, 2003). Asian American children straddle 2 cultures - on one hand conform to the demands of traditional Asian standards while accommodating Western culture. As a result, Asian American college women report lower self-esteem as well as less satisfaction with their racial definition (Sue & Sue, 2003). Asian American identity can follow one of four paths. They can assimilate, chooses Western culture over their Asian culture. In Asian American Cancer separate, only identify with their Asian culture. They can engage in integration or biculturalism, that is, maintained their Asian values, but learns the skills of the dominant culture. Lastly, marginalization may occur, reject their own culture but failed to adapt to the mainstream (Sue & Sue, 2003). Refugees have special considerations. Since 1975 approximately 1.5 million refugees have arrived from Southeast Asia (Sue & Sue, 2003). The Khmer, Laotian, Cambodian, and Vietnamese make up the majority. Typically, these immigrants do not have time to prepare for the move and consequently are under more stress than other immigrants. Many must wait and refugee camps in France, Austria, and the United States. Starvation of an immediate family member is common among Cambodians, Vietnamese experience conflict with the Viet Cong as a result of their association with the Central Intelligence

Agency. 86% of the Hmong wish to return to Laos, 75% experience unemployment, and 92% show stress related disorders. Refugees report family breakup, lack of community ties, experience homesickness, worry about the future, have difficulty with English, suffer unemployment, face culture shock, are unemployed, and have high levels of depression and post-traumatic stress disorder. In addition, Asians in general do not understand concept of psychotherapy and regard discussing family problems as a source of shame. Asian Americans look for strategies the solution based, and produce concrete results (Sue & Sue, 2003). Cognitive Behavioral Therapy (CBT) To achieve concrete results when serving Asian Americans Sue and Sue (2003) and Tracey (2006) recommend CBT. CBT grew out of the work of Aaron Beck and Albert Ellis, psychologist typically use it in conjunction with Rational Emotive Behavioral Therapy (REBT) (The Jove Institute, 2007). REBT works according to an ABC model - individuals experience an Activating event (A), reference the event to a Belief schema (B), and respond with a Consequence (C). The center piece of CBT is the Belief schema - it may be anxious, humorous, driven, rational or irrational. The schema is not necessarily bad, but maladaptive or irrational beliefs schema pose a threat to psychological health. For example, John is invited to a party - someone says something bad about John (A), John believes nobody likes him (B), and does not attend the party (C). C then takes another unhealthy turn, “I am all alone, therefore no one likes me”, thus reinforcing the irrational schema. The most difficult part of CBT is identifying the Belief schema, determining if it is unhealthy, and implementing a rational alternative to the client (The Jove Institute, 2007). Because CBT operates on such a basic level, it is applicable to many psychological disorders. However, there are certain central tendencies inherent in all CBTs. CBT is not a distinct therapeutic device, there are several approaches including Dialectic Behavioral Therapy, Rational Living Therapy, Cognitive Therapy, and Rational Emotive Behavioral Therapy (National Association of Cognitive Behavioral Therapist, 2007). Psychologists base CBT on a cognitive model on the emotional response of the client. That is to say, the thoughts of the client cause their feelings and as a result their behaviors, not situations, events, or people. The client benefits when we can change the way they think and as a result they feel better. CBT is time limit and therefore faster than traditional psychotherapy. Typically, the average number of treatments is about 16. Psychoanalysis, on the other hand, may take years. Clients know at the very beginning of therapy how long it will last. CBT is instructive in nature and uses homework assignments to reinforce the therapy. The client and the therapist decide when to end formal therapy. Most therapies depend on a good relationship between the therapist and the client - CBT focuses on teaching the client rational self counseling techniques. CBT is goal oriented - the therapist and the client look for the client's goals, and the therapist teaches and encourages achievement of those goals while the client expresses their concerns, learn, and implement the learning. Many forms of CBT rely on stoic philosophy, however - Cognitive Therapy, Rational Living Therapy, Behavioral Therapy, And Rational Emotive Behavioral Therapy do not. Stoicism emphasizes the importance of staying calm in an uncomfortable situation (NACBT, 2007). I use this myself, however - it sometimes unnerves of others, usually the ones that are not calm. CBT suggests in an uncomfortable situations we have to problems, our reaction to the problem, and the problem itself (NACBT 2007). CBT posits that we accept the problem and once we do will we automatically feel better and are able to use our intelligence, energy, knowledge, and resources to deal with the problem. Psychologists use the Socratic Method in CBT. CBT therapists need a good understanding of their client's issues. They encourage clients to question themselves. CBT is directive and structured. Cognitive behavioral therapist maintain an agenda for individual sessions, specific techniques and concepts, target what the client wants to achieve, allow clients to select the goal, educate clients on how to achieve those goals, and show clients how to do something not what to do. Psychologists base CBT on an

educational model. CBT make the assumption we learn behavioral and emotional reactions. CBT gears therapy to unlearn undesirable reactions and learn better ways of reacting. There is an additional gain with the educational aspect of CBT, when we understand how and why people can continue to do well even after therapy ended. CBT uses an inductive method. Many times things are not as they appear, therefore CBT Theory focuses on rational thinking, and fact based thinking. CBT therapists encourage clients to consider whether their assessment of a situation, determine if their assessment is rational, and if not, discourage them from wasting time about it. Home work is the centerpiece of CBT. CBT therapists assign homework, typically in the form of reading assignments in an effort to reinforce what the client has learned during therapy sessions (NABT, 2007). As I stated earlier, because of the basic nature of CBT, it lends itself to the treatment of a wide range of psychological disorders. For example, therapists use CBT in the treatment of chronically parasuicidal borderline patients with some success as compared to a “treatment as usual” group, there were decreases in measures of hopelessness, depression, reasons for living, and suicidal thoughts. The period of treatment was one year (Linehan et al. 1991). CBT has proved effective in the treatment of chronic fatigue syndrome as compared with a relaxation control group (Deale et al., 1997). 70% of the CBT group, 53 patients, achieved good results after 13 sessions and the results continue for at least 6 months (Deale et al., 1997). CBT is effective in treatment of acute stress disorder in an effort to prevent Post-Traumatic Stress Disorder (PTSD) even after six months after treatment - fewer patients met the PTSD criteria (Bryant et al., 1999). In another study, CBT shows effective in the treatment of a generalized anxiety disorder as compared to Behavioral Therapy - CBT subjects show lower measures of anxiety and depression, and higher measures of cognition (Butler et al., 1991). We use CBT in the reduction of anxiety in school children (Morris & Kratochwill, 1987). CBT is effective in the treatment of tinnitus, however – benefits were short lived and nonexistent after a six months follow-up (Davies et al., 1995). In 19 sessions over 18 weeks, CBT is as effective as interpersonal psychotherapy for bulimia nervosa, with a 48% success rate after six months (Fairburn et al. 1993). We have found CBT to be ineffective treatments for cocaine addiction for a variety of reasons including its short-term application as compared with other approaches, clinical trials that have shown it to be effective, it is goal oriented and a structured approach, flexibility, and its compatibility with other treatments (National Institute on Drug Abuse, 2005). For example, we can use Naltrexone in conjunction with CBT in treating alcoholism with some success (Anton et al., 2003). In a meta-analysis of 28 studies, we find that CBT is an effective treatment for depression, more effective than pharmacological therapy (Dobson, 1989; DeRubeis, 1999), behavioral therapy (Dobson, 1989), no treatment control, and other psychotherapies (Dobson, 1989). Interestingly, “Like other antidepressant treatments, CBT seems to affect clinical recovery by modulating the functioning of specific sites in the limbic and cortical regions. Unique directional changes in frontal cortex, cingulate, and hippocampus with CBT” in Positron Emission Tomography studies of CBT on depression (Goldapple et al., 2004). Discussion Cognitive Behavioral Therapy and Asian Americans Sue and Sue (2003) recommend using CBT with Chinese clients. Lin (2001) echoes this recommendation because he believes CBT is highly compatible with Chinese values, worldviews, cultural characteristics, and beliefs. He reports CBT we use extensively in the Chinese and Chinese American communities. For example, 53% of Taiwan therapists use CBT. One study showed a 62% rate of improvement for Chinese clients with psychotic and neurotic disorders, 79% to 87% with neurotic disorders and 82% with psychotic (Lin, 2001). Part of the attraction of to Asian Americans, is its directive, structured, goal oriented, and the time based qualities. In 2008, Sarah Horrell did a meta-analysis of culturally specific CBT

studies. There were only 12, 4 of which conducted with Asian Americans. The first study examines the effectiveness of CBT on depression in elderly Chinese Americans. Researchers recruit participants from a church and an apartment complex, they assign church members to the treatment group, and they randomly assign the apartment complex participants to either the treatment or control groups. The participants viewed a 25 minute videotape on CBT depression intervention. Participants showed significant improvements in depression and anxiety measures in the CBT group. The author points out the failure to randomly assign the church members may have contaminated the study. In another study, researchers randomly assign female Cambodian refugees to either a medication only or medication and CBT groups for treatment of PTSD. Here to, the author suggests the combination of treatments worked better. In the third study, Vietnamese refugees clinically diagnosed with symptoms of PTSD or randomized in either a CBT group or a wait list control group. Statistical analysis between groups showed the CBT significantly reduced PTSD symptoms. In another study, Cambodian refugees diagnosed with a combination of PTSD and Generalized Anxiety Disorder (GAD) or random Lee assigned to a CBT or wait list control groups. After completion of the CBT all the members of the control group still and symptoms of PTSD or GAD, 60% of the treatment group did not (Horrell, 2008). Conclusion Clearly, from a critical thinking point of view the qualities of directive, structured, goal oriented, and the time based problem solver on a broad range of psychological disorders make CBT a good fit for Asian Americans. Lin (2001) does warn even as a good fit some modifications to the therapy may need to be addressed. While the experimental literature doesn't amount to very much, it does look promising. References Anonymous. (2005). Dominant stereotypes about asian americans. retrieved on May 23, 2008 from http://www.asian-nation.org/index.shtml. Anton, R. F., Moak, D. H., Waid, L., Latham, P. K.,Malcolm, R. J., & Dias, J. K. (2003). Naltrexone and cognitive Behavioral Therapy for the Treatment of Outpatient Alcoholics: Results of a placebo-controlled trial. Retrieved on May 24, 2008 from http://focus.psychiatryonline.org/cgi/content/abstract/1/2/183. Bryant, R. A., Sackville, T., Dang, S., Moulds, M., & Guthrie, R. Treating Acute Stress Disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques. Retrieved on May 24, 2008 from http://ajp.psychiatryonline.org/cgi/content/abstract/156/11/1780. Butler, G., Fennell, M., Robson, P., & Gelder, M. (1991) Retrieved on May 24, 2008 from http://psycnet.apa.org/index.cfm?fa=search.displayRecord&uid=1991-15963-001. Davies, S., McKenna, L., & Hallam, R. S. (1995). Relaxation and cognitive therapy: A controlled trial in chronic tinnitus. Retrieved on May 24, 2008 from http://www.informaworld.com/smpp/content~content=a788689049~db=all. Deale, A. Chalder, T., Marks, I. & Wessely, S. (1997). Cognitive behavior Therapy for chronic fatigue syndrome: A randomized controlled trial. Retrieved on May 22, 2008 from http://wwwcache1.kcl.ac.uk/content/1/c6/01/47/68/25Deale1997.pdf. Dobson, K. S. (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Retrieved on May 24, 2008 from http://psycnet.apa.org/index.cfm?fa=search.displayRecord&uid=1989-30221-001. Fairburn, C. G., Jones, R., Peveler, R.C., Hope, R.A.,& O’Connor, M. (1993). Psychotherapy and bulimia nervosa. Long-term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy. Retrieve on May 22, 2008 from http://archpsyc.ama-assn.org/cgi/content/abstract/50/6/419. Goldapple, K., Segal, Z., Garson, c., Lau, M., Beling, P., Kennedy, S., & Mayberg, H. (2004). Modulation of cortical-limbic pathways in major depression. Retrieved on May 24, 2008 from http://archpsyc.highwire.org/cgi/content/abstract/61/1/34. Herrnstein, R. J. & Murray, C. (1994). The bell curve. New York: Simon and

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