12/11/2017 there has been an increased attention and research


Name: Seidu Bawa

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Class: PYS

Assignment: Integrating
multicultural therapy with cognitive behavioral therapy

Jennifer M. Karalekas, Ed. D

            In recent years, there has been an
increased attention and research on the influence of multiculturalism and the
need for mental health practitioners to incorporate cultural sensitivity when
serving clients of different ethnic and diverse background. The purpose of this
paper will be to focus on the application of multicultural therapy approach
(MCT) with cognitive behavioral therapy (CBT) in servicing underserved, low
income communities, migrant families and inner city individuals with cultures
that may differ from that of the practitioner. Even though this particular
approach is in its early stages, progress is being made and more practitioners
are starting to recognize its importance due to the scientific research
involved and the empirical evidence of data collection with cognitive
behavioral therapy. Cognitive behavioral therapy (CBT) as explained in class is
a goal oriented collaborative approach based on scientific evidence whose core
principle is to challenge the client’s negative beliefs developed due to past
experiences and emphasis is put on restructuring the client’s dysfunctional beliefs
with homework assignments and other techniques. MCT on the other hand takes
into consideration the cultural background of the client, religious adherence,
spirituality, past experiences and cultural values which the clinician could
consider during the therapeutic process. While the convergence of these two
approaches may provide practitioners with a wealth of information that will
allow them to understand their clients a bit more, there are potential
limitations to consider when merging the two approaches. I’ll discuss the advantages
of these approaches for both client and clinician and the potential limitations
critics fear it may counterproductive integrating the two and how such
limitation could be used as opportunities to improve the effectiveness of
merging MCT and CBT.

            The purpose of this paper and the
reason I focused my research on this topic is because of my interest to work
with migrants and minority families in underserved and low income communities
who are finding it difficult transitioning in their new found home. As a
minority with a different cultural background and upbringing from that of the
dominant culture, I’ve noticed the lack of diversity in mainstream mental
health practitioners and sometimes the imposition of the dominant cultural
awareness of self on the minority culture without even realizing it. Such
biases could lead to misdiagnoses by the clinician during the diagnostic and
assessment phase because certain cultural aspects were not factored in thereby
prolonging treatment.  I’m also
fascinated by the cognitive abilities of individuals and I’m on the belief that
a person’s mental faculty is the single most important tool he/she possess and
if he/she can alter his/her thoughts and outlook about self, he/her can discover
new potentials in defeating their self-doubt and are capable of reinventing
themselves and accomplishing greater things. It is important for me, as a
clinician or mental health practitioner to reconcile the two in order to be a
better practitioner with less implicit biases due to the wealth of information
I’ll be exposed to from evidence based scientific research in CBT.


Culture is a
sensitive topic for most people especially among minority and migrant
communities. Culture goes beyond self-identity: its social support,
self-awareness and a sense of belonging, so when a client can’t connect with
the clinician; little to nothing would be achieved during therapeutic treatment.
There is the need to establish trust, empathy and understanding while rendering
service to individuals of such demography. Considering the cultural beliefs and
background of the client could provide an in-depth understanding regarding the
client’s genuine concerns. But often times due to the sensitive surrounding
people’s culture on their outlook on life, it’s been found that mainstream
psychologies either avoid discussing it or viewing it as a separate entity from
the individual’s experience. Factoring in the client’s experience, culture loss
due to migrating willingly or for political unrest and culture grievance could
be keys to unraveling the client’s state awareness. Cultural grievance could
manifest in the form of depression, increased anxiety, low self-esteem,
self-doubt, isolation and the feeling of rejection by the dominant culture. I
can attest to such feeling because I was a teen migrant myself a certain point
in my life and while I was grieving a cultural loss, a school councilor
reported that I was just being uncooperative. The stress of acculturation was
not accounted for: it was rather a disengaged evaluation and a quick assessment
to caste me as the other. Marginalization
of such cultural bereavement especially among minority group is wide spread in
the psychology world. Mainstream psychological research still ignores the
centrality of culture and separates studies that include cultural minorities
(or that simply address cultural influences) into the separate domain of
cross-cultural or multicultural psychology (Clark, 1987).  MCT encourages the clinician to consider the
individual’s environment, lifestyle, social support and belief system during
the assessment period. Contextualizing all these aspects could provide the
clinician a glimpse of the client’s cognitive function and how they perceive
themselves and the world at large.

Cognitive Behavior Therapy

CBT as explained in class puts an emphasis on the
individual’s abilities to self-improve through cognitive restructuring, coping skills
and homework assignments in a collaborative effort to change the client’s thoughts
and beliefs, and their maladaptive behaviors. CBT is becoming more appealing to
most clinicians because of its reliable scientific data and the empirical
evidence it provides. Its adaptation by clinicians demonstrates the importance
of tangible information and results oriented approach that clinicians may
reference to incorporate in their practices. It’s been reported that there has
been countless researches and publications of CBT in the past decade alone. A
survey of over 2000 councilors, social workers and psychologist found that approximately
69% using CBT (Psychotherapy Networker 2007). Another poll of practicing
psychologist found that 89% of the 470 respondents used CBT (Meyers 2006).
These statistics shows how quickly mental health practitioners are embracing CBT
because of its widely researched evidenced based approaches. The uniqueness of
the client is the central focus of the therapist in CBT and its core principle
is to work collaboratively with the client to make them realize their uniqueness.
Another aspect of CBT mentioned in class is that it is time limited unlike
other psychotherapy techniques so clinicians utilizes the various approaches of
CBT that best fit the client situation. Some of these different approaches of CBT
are rational emotive behavioral technique or REBT and cognitive therapy. CBT
clinicians’ assumptions are that our emotions drive our feelings and thoughts and
those emotions develop into rational or irrational thoughts that fuel our perception
of ourselves and the world. Albert Ellis, one of the pioneers of CBT later
developed the REBT approach explained it as “an action-oriented psychotherapy
that teaches individuals to identify, challenge, and replace their
self-defeating beliefs with healthier ones that promote emotional well-being
and goal achievement.” The goal is to undo the “victimhood” mind set of the
client and help them modify their thoughts on the outlook of life. The second
most significant form of CBT is cognitive therapy developed by Aaron T. Beck in
the 1960’s is used in the treatment of depression. According to Beck, people’s
view of certain life events contributes to their cognitive distortion. Both CBT
approaches put an emphasis on modifying the client’s thoughts and internal
dialogue in combating self-doubt and victimhood.

CBT and MCT shared similarities

     There are certain
similarities shared by both approaches and when implemented during the
therapeutic processes could be a success in achieving the therapeutic goal.  A person’s culture influences their perception
of themselves and of others; and places emphasis on the uniqueness of their
individuality, so does CBT. Secondly, they both focus on empowering the client
in achieving better goal and realizing their potentials. For example, CBT
empowers the client through educational approach by giving the client homework
and challenging them to try something that they normally wouldn’t because they
fear they will be rejected. On the other hand, MCT also empowers the client by
reminding them on how they find meaning in and strength in their cultural
identification. Another aspects shared by both MCT and CBT is respect for the
clients point of view. Their input is valued and their irrational thoughts are
replaced with rational thoughts rather than being ridiculed. And both work
collaboratively with the client in achieving an attainable end result without
the clinicians imposing their personal beliefs.

Potential limitations

     Although the
integration of these two approaches provides clinicians with a wealth of
information to work with, there is a need for more research especially among
minority groups. Some aspects of CBT may be in conflict with that of MCT in
their application. Firstly, CBT recommends clients to be vocal, very assertive
and independence during the therapeutic process. While with MCT, subtle
communications are valued over assertiveness in most cultures, interdependence
over personal independence (social support) and finally listening and observing
instead of questioning and  behavior are
seen as spirituality rather than a world view (Jackson,  Schmutzer, Wenzel & Tyler 2006). Even
though both take into account the personal history of the client during the
assessment process, however CBT gives more attention to the here and now, and
that could lead to a neglect of the past. The history of the client’s culture
could be vital into unraveling what may have caused their outlook in life.
Being aware of these potential limitations and recognizing them will only give
room for more research on how these two could work together rather than
preclude their integration.  

Integration of CBT and MCT

In a diverse and multicultural society like North America,
linear approach to therapy to a migrant family going through cultural
bereavement would not be understood if the whole aspect of the circumstance
surrounding their migration is not taken into consideration. Culturally
competent clinicians would take into account the families overall history,
environmental events and situations that caused them to migrate. For instance,
a family that migrated due to political unrest may grieve differently from a
family that migrated willingly for the purpose of a better opportunity. Language
barrier, economic hardship and the feeling of rejection may affect the migrant
family’s self-esteem and self-worth. When that is the case, the culturally
competent clinicians may teach the clients cognitive restructuring.  Through cognitive structuring, the migrant
family may learn to undo certain dysfunctional thoughts by recognizing common
cognitive errors they might have developed due to their circumstance. The
therapist long term goal is to get the client to be aware of their irrational
thoughts without undermining their experience.

Also, respecting the clients personal experiences and input
during the therapy session are emphasized by both MCT and CBT. Respect is an
important integral part a therapeutic process that could help in the
establishment of trust. And since CBT is a collaborative therapeutic approach,
caution must be taken on the part of the clinician in being sensitive to
client’s external factors rather than just the internal factors. So there when
considering given the client therapeutic assignments, the culturally competent
clinician could implement an important tool of MCT which is Social support. Considering
external factors with respect to the client’s culture even though CBT mainly focuses
on the internal dialogue of the client could facilitate a better therapeutic
relationship. The importance of culture in the expression of grief was
highlighted by a case report of bereavement in an Ethiopian female refugee. Her
symptoms of grief were complicated by her inability to perform her culturally
sanctioned purification rituals because of her relocation. Compounding her
problem, she was erroneously diagnosed at various times due to the use of
Western derived diagnostic criteria and a lack of appreciation of the cultural
differences in the presentation of grief by clinicians (13). The
symptoms of cultural bereavement may be misdiagnosed due to problems with
language, culture and the use of Western diagnostic criteria in non- Western
peoples. Schreiber (13) noted
that traditional healing and purification rituals as well as supportive
psychotherapy, after the correct diagnosis was made, were essential in the
treatment of this patient’s syndrome. Additionally, to alienate the client’s
core cultural beliefs may be perceived as disrespectful. Individuality is encouraged
with respect to environment in MCT; however both put an emphasis on acknowledging
the situation that created the event.

 And also subtle
response, lack of eye contact and unassertiveness are a sign of respect in most
Asian and African culture. Therefore, repetitive questioning while
communicating may be seen as disrespect in certain cultures and societies (Weisman
et l 2005). Nodding and being silent in-between questions to give the client time
to formulate their response is encouraged in cultural responsive CBT.  Such caring attitude during treatment is
helpful in establishing trust when restructuring the client’s cognitive
thoughts. It shows the culturally competent clinicians validates the clients
experiences by actively listening instead interrupting them midsentence and
challenging their personal experiences. 
Moreover, A loss of culture congruity can be depressive among migrants
who have been forcibly removed from their birth places due to political unrest.
Therefore, homework assignments during the therapeutic process should include a
culturally related strength and support system that would remind the client of coping
skills. It could be a list of question that they can ask their family members
to remember pass success or repeated phrase that would remind them of how resilient
they are. A visit to religious monastery or a cultural center or a particular song
could be helpful in reminding them that you value their spirituality and
cultural beliefs. The culturally responsive CBT clinician role in the therapy
is to remind the clients that their irrational fears are innate and so are
their rational ones, and together they’ll work collaborative to make them
realize their worth and to not be victims of their circumstances.


Multiculturalism therapy values the client’s experiences and
encompasses open minded on the part of the therapy and client. Culturally competent
clinicians are flexible and cherish the importance of culture in shaping people
outlook of life so therefore they consider their every aspect of the personal
history during the therapeutic process. Like I mentioned in the introduction,
MCT provides clinicians with a wealth of information to work with because of its
well-researched and recorded technique that’s making more appealing to most
practitioners. And with CBT, its expanded approach in considering the overall
cultural aspects of the client that influences their outlook is beneficial to
both therapist and client at such. Although the integration of these two
approaches, MCT and CBT are in their early stages with potential limitations,
research has shown; they’re more promising in their relevance and effectiveness
due to the wealth of information and empirically base evidence that clinicians
are exposed to.

And lastly, the reason I chose to
do my research paper on the multicultural therapy approach and Cognitive
behavioral approach is to better understand and conceptualized the struggles
migrant families like myself whose parent has been in this country for almost
three decades. I still remember how difficult the transition process was when I
first migrated as a teenager; living behind everything familiar to me to a land
unfamiliar to me in every aspect. I felt constraint and restricted, my head was
spinning; I was in constant thought process which later, I and other migrant
kids came to find out it was depression, we just knew we’re miserable. I saw
myself and the struggles I went through as a young migrant when this topic was
discussed in class. And the worth part of it was the lack of mental health
councilors that are well equipped with the cultural awareness to deal with a
changing demographic in underserved and low income communities. I found solace
and support in other migrant families in the neighborhood. Even though some
share no cultural similarities with me, we share something in common and that
is culture grievance and with that we empowered one another and found a voice within
that grievance. To be a trained clinician in cognitive behavioral therapy with
competency in culture to have the necessary tools to help other minority group
in overcoming their grievance and to not experience low self-esteem and self-doubt
is my hope.