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Ten Steps to Culturally Competent Evidence-Based Practice . Pamela A. Hays, Ph.D. www.drpamelahays.com. Agenda. 8-8:30am The Evidence-Based Practice of CBT: An Overview Cross-Cultural Strengths & Limitations of CBT 8:30-9:50am A New Framework For ADDRESSING Diversity Break 10-11:50am

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ten steps to culturally competent evidence based practice
Ten Steps to Culturally CompetentEvidence-Based Practice

Pamela A. Hays, Ph.D.




The Evidence-Based Practice of CBT: An Overview

Cross-Cultural Strengths & Limitations of CBT


A New Framework For ADDRESSING Diversity



10 Strategies for Culturally Competent CBT

evidence based practice in psychology
Evidence-Based Practice in Psychology:

Integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.

– APA Presidential Task Force on EBPP, 2006

historical cultural development
Historical/Cultural Development




systems Humanistic/Existential/




behavioral principles
Behavioral Principles
  • Emphasis on here & now.
  • Person X Environment = Behavior
  • All behavior is learned.
behavioral principles1
Behavioral Principles…
  • Adapt methods to each person’s situation, needs, & strengths.
  • Set clearly defined achievable goals.
  • Ongoing assessment.
5 components of cbt
5 Components of CBT
  • Environment/Situation
  • Emotions
  • Sensations
  • Behaviors
  • Cognitions
cbt problem conceptualization
CBT: Problem Conceptualization

A. Environmental/External

B. Cognitive/Internal

--overwhelming emotions

--disturbing physical sensations

--self-defeating behaviors

--unhelpful thoughts/images

problem type intervention



Environmental changes

Support groups

Behavioral skill building

Assertiveness training

Relaxation training

Modeling, reinforcement

Competing behaviors

Cognitive restructuring

Problem Type Intervention
cognitive restructuring def
Cognitive Restructuring (def.)

--involves changing unhelpful thoughts and images to more helpful ones, to manage overwhelming emotions & physical sensations, and change self-defeating behaviors.

strengths of cbt across cultures
Strengths of CBT across Cultures
  • Emphasizes the uniqueness of each individual.
  • Empowers clients via educational approach.
  • Focuses on conscious processes & specific behaviors.
  • Integrates assessment throughout therapy.
  • Emphasizes strengths & supports.
  • Works across the lifespan (children, adults, elders).
  • Considers cognitive, emotional, physical, behavioral & environmental components of a problem.
limitations of cbt across cultures
Limitations of CBT across Cultures
  • Often assumed to be value-neutral.
  • Emphasis on cognition, “rational” thinking, & confrontation.
  • Focus on the present may result in neglect of generational & historical influences.
  • Emphasis on personal change may contribute to neglect of oppressive environmental conditions.
  • Heavy reliance on verbal abilities.
  • Research is still predominantly ethnocentric.
  • CBT jargon.
  • Neglects the spiritual component.
the addressing framework
The ADDRESSING Framework

Cultural InfluencesMinority Groups

Age/generational Children, adolescents, elders

Developmental disabilities People with developmental disabilities

Disabilities acquired People with disabilities acquired later in life

Religion & Spirituality Religious minority cultures

Ethnic & racial identity Ethnic & racial minority cultures

Socioeconomic status People of lower status by educ, income,

occup, rural habitat

Sexual orientation Gay, lesbian, & bisexual people

Indigenous heritage Indigenous/Aboriginal/Native people

National origin Refugees, immigrants, international students

Gender Women, transgender people

two categories of work
Two Categories of Work
  • Personal
  • Interpersonal
essential knowledge
Essential Knowledge

1. Bias is best thought of as a tendency to

think, act, or feel in a particular way.

understanding bias
Understanding Bias

Generalizations Biases

& Biases  Worldview

Categorizations Biases

essential knowledge1
Essential Knowledge…

2. We’re all biased but we don’t all belong to dominant cultural groups.

3. Bias + Power = Systems of privilege (‘isms).

4. Nonprivileged members are socialized to be aware of the lines separating those who have privilege from those who do not.

5. Privileged members are socialized to ignore these lines and differences.

the addressing framework1
The ADDRESSING Framework

Cultural Influences

Age/generational influences

Developmental disabilities

Disabilities acquired later In life

Religion & Spirituality

Ethnic & racial identity

Socioeconomic status

Sexual orientation

Indigenous heritage

National origin


culturally responsive cbt
Culturally Responsive CBT

1. Assess Needs w/emphasis on Respectful Behavior.

a. Explain what you do w/o jargon.

b. Slow down questioning process.

c. Use ADDRESSING to develop hypotheses.

d. Avoid questions that elicit negatives re: family or


e. Assess whether person wants change/what kind.

cr cbt
  • Use ADDRESSING framework to generate Strengths & Supports List.

a. What do you consider your strengths & supports?

b. What would your mom/kids/friend say?

c. Do you have a connection to any religion or spiritual practice?

culturally related personal strengths
Culturally Related Personal Strengths
  • pride in one’s culture
  • religious faith or spirituality
  • artistic and musical abilities
  • bilingual and multilingual skills
  • group-specific social skills
  • sense of humor
  • culturally-related knowledge & practical skills (fishing, hunting, farming, medicinal plants)
  • culture-specific beliefs that help one cope with others’ prejudice & discrimination
  • respectful attitude towards the natural environment
  • commitment to helping one’s own group
  • wisdom from experience
interpersonal cultural supports
Interpersonal Cultural Supports
  • extended families including non-blood-related
  • cultural or group-specific networks
  • religious communities
  • traditional celebrations and rituals
  • recreational, playful activities
  • story-telling activities that make meaning and pass on history of the group
  • involvement in political/social action group
  • a child who excels in school
environmental cultural supports
Environmental Cultural Supports
  • altar in home to honor deceased family members
  • space for prayer and meditation
  • culture-specific art and music
  • culturally preferred foods for cooking & eating
  • animals to care for
  • gardening area
  • access to outdoors for subsistence or recreational fishing, hunting, farming, observing night sky
  • communities that facilitate social interaction by location or design
3 consider cultural influences on the 5 components of cbt
3. Consider Cultural Influences on the 5 Components of CBT:
  • Environment
  • Emotions
  • Sensations
  • Behaviors
  • Cognitions
environment cultural considerations
Environment + Cultural considerations
  • Recognize cultural influences in the environment
  • Acknowledge oppressive aspects of the situation
  • Validate client’s personal experience of oppression
emotions cultural considerations
Emotions + Cultural Considerations
  • Consider differences in emotional expressiveness
  • Consider differences in reporting emotion
sensations cultural considerations
Sensations + Cultural Considerations
  • Consider somatic expressions of distress
  • Consult with physician regarding somatic complaints.
behavior cultural considerations
Behavior + Cultural Considerations
  • Recognize that culture shapes all behaviors.
  • Be familiar with culture-bound syndromes.
cognition cultural considerations
Cognition + Cultural Considerations
  • Consider cultural values that affect perceived options.
  • Consider cultural norms (beliefs) including different definitions of rationality, adaptive/maladaptive behavior, & health.
cr cbt1

4. Clarify what part of the problem is primarily external & what part is primarily internal.

a. Validate experiences of oppression.

cr cbt2

5. For External, consider Culture w/:

  • Problem-solving
  • Environmental changes
  • Support groups
  • Behavioral skill building
  • Assertiveness training
  • Relaxation training
  • Modeling, reinforcement
  • Competing behaviors
cr cbt3

6. For Internal problem, use Cognitive Restructuring w/ emphasis on collaboratively exploring the helpfulness of a thought, belief, or image (rather than rationality or validity).

cr cbt4

7. Be cautious about the Downward

Arrow Technique

(e.g. “So what if that were true?” “What is the

worst that could happen?”)

cr cbt5

8. Do not challenge a core cultural belief unless client is open to this.

cr cbt6

9. Use Culturally Related Strengths & Supports List to generate more helpful thoughts & images.

cr cbt7

10. Develop culturally congruent

homework that emphasizes

client direction.

culturally responsive cbt1
Assess needs w/emphasis on respectful behaviors.

Use ADDRESSING to generate Strengths and Supports List.

Define the 5 Components w/ Cultural considerations.

Clarify External & Internal parts of problem.

For External part, use Environmental Intervention w/Cultural considerations.

For Internal part, use Cognitive Restructuring that collaboratively considers helpfulness of thoughts.

Be cautious w/Downward Arrow Technique.

Don’t challenge core cultural beliefs.

Use Culturally Related Strengths & Supports List to generate helpful thoughts.

Culturally congruent Homework w/client direction.

Culturally Responsive CBT
a major obstacle to culturally competent evidence based practice is defensiveness
A major obstacle to Culturally Competent Evidence-Based Practice is DEFENSIVENESS.
think of a situation with a person in which you began feeling defensive
Think of a situation with a person in which you began feeling defensive:
  • What led to your defensive feelings?
  • What were your physical sensations & emotions?
  • What were you thinking?
  • What did you do? What did you say?
  • What did the other person do & say?
  • Did you spiral down or were you able to stop the spiral?
preventing defensive behaviors
Preventing Defensive Behaviors
  • Become aware of physical sensations related to feelings of defensiveness.
  • In the moment, take a deep breath, exhale slowly, and focus on your breath.
  • Refrain from defensive behaviors .
  • Ask yourself: What does this person want?
  • Try focusing on the content (vs. voice tone, volume, or nonverbal behaviors ).
preventing defensive behaviors1
Preventing Defensive Behaviors…

6. Question the need for this person's views to match your own.

7. Reframe irritations & annoyances as opportunities for growth.

8. Recognize your need for additional information and/or experience.

9. If appropriate, discuss the limitations of your knowledge and experience with the person.

10. If appropriate & possible, use humor.

resolving value conflicts
Resolving Value Conflicts
  • Look for the shared value.
  • Recognize differences in value priorities.
  • Reframe differences using positive language.
reframing value differences

Egalitarian vs. Authoritarian

Independent vs. Dependent

Open vs. Closed

Change vs. Resistant

Hard work vs. Lazy

Honest vs. Dishonest

Active vs. Resigned




Self-Control, Mature


Enjoys life



Reframing Value Differences