CT with African Americans

Ethnic awareness requires the recognition of potentially large differences in values and experiences between patient and clinician. Interdependence, spirituality, and discrimination are consistently cited markers of cultural difference between mainstream and ethnic/minority populations (Hall, 2001). Despite mounting evidence of the importance of cultural competence in working with ethnically diverse patients, clinicians often make the mistake of overlooking or misunderstanding these constructs as they operate among ethnic/minority patients.

African Americans are likely to differ from the dominant culture regarding conceptualization of self, valuing sociocentrism rather than ego-centrism (Randall, 1994). Sociocentrism emphasizes the importance of role fulfillment and interdependence within the social network as opposed to autonomy and individuation. This lack of desire for complete independence can be misinterpreted as passivity or weakness and dependence, resulting in a negative evaluation of an engrained cultural value and the erroneous assumption of a necessity for drastic change. Aside from obvious differences in core values and beliefs, it is also quite possible for seemingly similar values to gain varied expression based on ethnicity. Spirituality provides a prime example; the same religion is often practiced in radically different ways (Hall, 2001). Assumptions of similarity in behavioral expression without consideration for culturally mediated differences are ripe for producing instances of extreme misunderstanding. Likewise, symptoms of psychological disorders may have significantly different manifestations across cultures. Indeed, it is not uncommon for African Americans to express intense irritability as an indicator of depressed mood rather than the prototypical sadness typically associated with depression (Kohn, Oden, Munoz, Robinson, & Leavitt, 2002).

Discrimination is perhaps the most pervasive construct, with particular relevance to therapy with African American patients. By and large, all African Americans share the experience of discrimination, and in multiple domains. Perceived discrimination is likely to have a large impact on therapy wherein possible reasons for early termination may include therapist mistrust and cultural insensitivity (Carter, 1999). Consequently, it is important that clinicians not only recognize the significance of discrimination as it is uniquely perceived by each African American patient but also highlight the contribution of sociopolitical, historical factors to the experience ofpsycho-logical distress to circumvent misattribution of blame directed toward the patient (McNair, 1996). Maintaining open acceptance of an African Ameri can patient's reality further promotes ethnic awareness and offsets the tendency toward hasty (often negative) evaluation in lieu of considering the potentially adaptive functions of culturally mediated thoughts and behaviors. However, although the possibility of minimizing distressing phenomena among African Americans exists, circumstances that might differentially predict either over- or underpathologizing have yet to be investigated (Sue, Zane, & Young, 1994).

In addition to discrimination, it may be important to adapt other constructs. Randall (1994) indicates the likely impact of differing time orientations on therapeutic goals. Failure to recognize ethnic differences in time orientation can lead to misinterpretations of lateness and appointment inconsistency as resistance or lack of motivation. These would be inept conclusions in reference to individuals for whom time is not necessarily an economic commodity that is scheduled well into the future, but perhaps a resource well spent in the present. For many African Americans, the past may hold paramount importance for their present lives, rendering an orientation toward the future as essentially meaningless. Traditional therapeutic goals such as "planning ahead" and adhering to strict assignment schedules may have less relevance for African American patients.

Unfortunately, research on the adaptation of psychotherapy to meet the particular needs of African American patients is sparse. To date, few studies have reported on the outcome of culturally adapted therapy tailored specifically for African Americans. Our study of applied structural (process-based) and didactic (content-based) adaptations to CBT interventions with depressed, low-income African American women indicated that ethnic-specific changes to CBT may be useful (Kohn et al., 2002). Our structural adaptations included closed group therapy sessions within only African American women, language modifications negotiated by the group, and the use of culturally derived anecdotal examples. Didactic adaptations included therapeutic foci on issues relevant to African American women's lives, including healthy relationships, spirituality, family, and African American female identity. Results demonstrated that culturally adapted CBT was more efficacious than traditional CBT in lowering reported levels of depressive symptom intensity. Therefore, greater effectiveness of culturally adapted therapy suggests that traditional CBT may become less effective as groups differ from the original intended population of the intervention.

Other adaptations have been proposed for work with African American patients based on associated cultural values and experiences, though these have not been empirically demonstrated in terms of outcome. Specific to CT, Randall (1994) encourages prudent use of reattribution as a therapeutic technique given that explanations of events may be culturally relative.

In therapy with an African American patient, it may indeed be more useful to openly accept reality as it is perceived and presented rather than to challenge the patient's ability to assess the current milieu appropriately (McNair, 1996).

Group psychotherapy has been cited as a useful approach for working specifically with African American women, for whom a promoted sense of sisterhood may help to combat common feelings of alienation, loneliness, and daily stress (Boyd-Franklin, 1987). It is suggested that combining the collective benefits of an intensive support group and the psychotherapeutic treatment goal of behavior change, results in a therapeutic support group hybrid that allows black women to address a variety of problems including anxiety, symptoms of depression, and low self-esteem. Furthermore, pervasive burdens associated with managing family responsibilities, maintaining healthy relationships, and contending with workplace discrimination are also addressed. African American women's groups should include six to eight members to promote an atmosphere of intimate sharing, while also allowing for periodic absences.

In contrast to the larger adaptations proposed by some researchers, others suggest that practical and relatively minor enhancements to current psychotherapy interventions are also likely to have a beneficial impact on treatment effectiveness for African American patients. Addendums as simple as bolstering the plan of assessment with additional measures based on possible confounding factors likely relevant among African Americans may go a long way in improving quality of therapeutic intervention (Carter, 1999). For example, the inclusion of medical evaluations, as well as acculturation and racial identity scales, may explain a great deal in terms ofvariance introduced by the extensive within-group heterogeneity of the African American community. Another relatively simple yet extremely useful enhancement is the implementation of immediate symptom relief strategies (e.g., behavioral activation, relaxation training) to help decrease high rates ofattri-tion among African American patients.

However, some cultural enhancements that are proposed to be efficacious require more than minimal effort by clinicians. These pertain to the necessity of environmental intervention to ensure that conditions for therapy are met at the very basic level of access to social services and emergency assistance (Randall, 1994). Such an enhancement highlights the critical relevance of increased clinician knowledge of current public policy for treatment effectiveness. Pertinent public policy issues for many African Americans include boundaries to adequate treatment (e.g., managed care disparities) that extend beyond patients' immediate control into sociopolitical realms and require proactive professional assistance (Boyd-Franklin,

2003). Although worthwhile recommendations have been offered for the apparent benefit of these proposed enhancements, evidence-based outcome research based on successful implementation of the aforementioned treatment improvements has yet to appear in the literature.

Finally, it is important to recognize the considerable within-group heterogeneity of the African American community. Individual differences often play a larger role than presumed cultural norms in expressed values and behaviors. Furthermore, almost nothing is known about gender differences among African Americans' response to treatment. Thus, as with all patients, it is necessary to address directly and negotiate values and goals in therapy with African American patients to ensure clarity and the maintenance of respect for both cultural and individual differences (Boyd-Franklin, 2003). Open negotiation has the added benefit of increasing sense of empowerment, an area of intervention that can be particularly useful in therapy with African American patients (Carter, 1999).

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