CBT and Multi Cultural Influence

Cognitive Behavioral Therapy in contrast to many other therapeutic frameworks has both an explicit rationale and an empirically demonstrable success rate. In addition to the wealth of published case histories there are a plethora of controlled studies attesting to the efficacy of CBT interventions with an equally diverse range of psychological and behavioral conditions. (Emmelkamp et al 1992). Cognitive behavioral therapy (CBT) is a type of therapy that aims to help a person manage their problems by changing how they think and act.

It is a problem solving approach which recognizes that clients have a behavioral difficulty rather than that they are a behavioral problem. It encourages them to talk about how they think in relation to themselves, the world, other people and how what they do affects their thoughts and feelings. CBT can help to change how a person thinks (‘cognitive’) and what they do (‘behavior’), thus helping them to manage difficulties and feel better about life.

Unlike most psychotherapies which only work with talk and reflections, CBT regards behavioral acts as primary. Treatment involves clients engaging in personal behavioral experiments, ‘practice makes perfect. ’ For many behaviorally based problems such as phobias obsessive compulsive disorder bulimia and the like there simply is no substitute for this way of working. Direct behavioral experience is often the most effective medium for articulating change.

Action, that is, sometimes speaks far louder than words. To benefit fully from CBT, clients need to be committed to the process, maintain any homework agreed such as keeping a diary or undertaking experiments/challenges jointly agreed and/or decided upon between client and counsellor. It can help the client make sense of overwhelming problems by breaking them down into smaller parts. The outcomes of homework are reviewed and feelings discussed at each subsequent session.

Most importantly CBT is a collaborative and empowering process in which the client is an active participant. Autonomy: respect for the client’s right to be self-governing BACP Ethical Framework for Good Practice in Counselling & Psychotherapy. A principal goal of this collaborative process is to help clients effectively define problems and gain skills in managing these problems. As in other therapies, CBT also uses other elements of the therapeutic relationship, such as rapport, genuineness, understanding, and empathy.

The number of sessions required varies greatly depending on the presenting issues/problems and objectives, sessions usually lasting from anywhere between six weeks to six months. The client is helped to see how their thoughts and behavior relate to the way they feel, how this might contribute to the problems being experienced and that it is not the situation itself making them unhappy, but how they think about and react to it. CBT can help clients find ways to change thought patterns and behavior and to solve problems and anxieties better, but it cannot remove the problems.

The skills learnt within CBT are useful, practical and helpful strategies that once learnt can be incorporated into an individual’s life to help them handle difficult situations better when future stresses and difficulties arise. However there is always a risk that the bad feelings associated with the clients problem return, but with CBT skills it should be easier for them to control these. Even after the client is feeling better and sessions have ended, it is important to emphasis the need to practice the skills acquired.

CBT focuses on the individual’s capacity to change themselves their thoughts, feelings and behaviors it can help to manage problems, such as anxiety and depression, so they are less likely to have a negative impact on their life. However because of its structured nature, it may not be suitable for people who have

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more complex mental health needs or learning difficulties. Some critics argue that because the therapy only addresses current problems and focuses on very specific issues, it does not address the possible underlying causes of mental health conditions, such as an unhappy childhood.

Neither does it address wider problems in systems or families that often have a significant impact on an individual’s health and well-being. Research has shown that cognitive behavioral therapy (CBT) can be as successful as medicine in treating many types of depression and other mental health disorders it can be completed in a relatively short time compared with other talking therapies and because it is highly structured, CBT can be provided in a number of different formats such as through computer programs, groups and self-help books.

Some research suggests that CBT may be better than antidepressants at preventing the return of depression. It is thought to be one of the most effective treatments for anxiety and depression. When considering the significance and use of Cognitive Behavior Therapy within therapeutic practice (as with any other modality used) it is necessary to consider the impact/context within todays multi-cultural society. Awareness of Multiculturalism provides a fourth dimension to the three traditional helping orientations psychodynamic, existential-humanistic and cognitive.

All learning occurs and identities are formed within a persons cultural context. Cultural identity is dynamic and ever changing in todays society. Understanding the cultural and socio-political context of a client’s behavior is essential to accurate assessment, interpretation and treatment. It is imperative as counsellors to have and maintain increased self-awareness, as an essential starting point in developing multicultural competence.

The appropriate application of skills in multicultural settings depends on both cultural awareness and relevant knowledge of the counsellor. ‘it is incumbent upon the individual practitioner to be knowledgeable about his or her own multicultural reality in order to use that information effectively in work with clients of various ethnicities, genders, ages, socioeconomic classes, religions, sexual orientation, differing abilities, and with those who use different languages’ Baldwin 2nd ed (2000 pg 167)

Recognizing the importance of the many variables within modern day society such as, ethnicity, nationality, religion, variables such as age, gender and place of residence status variables such as social, educational and economic, and affiliations including both formal affiliations to organizations or families and informal affiliations to ideas and a lifestyle is essential to the effectiveness of any counselling therapy. It takes a olistic and intuitive approach to work within todays multi-cultural society, respecting that each person has many different cultures or identities with each identity becoming relevant at different times and places. One example worthy of consideration is metaphors, clients often use metaphors within therapy, recognizing that metaphors are and can be culturally bound and reflective of particular values, for example ’time is money,’ is an important consideration when working with clients.

Implicit in their use are models of perception, thus the phrase ‘things are looking up’ not only conveys the message that things are improving but also reflects the idea that ‘up’ is good. The identification of the color black with bad things is frequently used metaphorically, in a way which reflects and reinforces the negative connotation given to all people and things black. The power of metaphors derives from the models which they provide for understanding, thinking and communicating about the world.

Multiculturalism emphasizes both the way we are different from and similar to other people and is a situation in which all the different cultural or racial groups in a society have equal rights and opportunities, and none is ignored or regarded as unimportant. Thus avoiding discrimination, whilst also appreciating the difference and diversity between people. Justice; the fair and impartial treatment of all clients and the provision of adequate services BACP Ethical Framework for Good Practice in Counselling & Psychotherapy.

Culture provides an adult/child with a particular way of look at the world, thus emphasizing some tendencies to the development of schemas and or rules and assumptions. In some countries the culture is still quite autocratic and male dominated, therefore leading to ideas about the importance of men, yet others are characterized as competitive and or oppressive. All these factors will affect a clients personality and ways of functioning. As we become more of a multi-cultural society culture becomes an even greater factor in the therapeutic relationship today and worthy of much care and consideration.

According to Beck et al. (1979) clients tend to suffer from a ‘cognitive triad’ of negative beliefs, which includes negative beliefs about themselves, the world in general and their future. Beck also outlines three more components of his theory of depression, including automatic thoughts, schemas and logical errors. Margaret Hough 2nd ed (2002 pg,139) A central focus of Beck’s work with clients is to helping them change their faulty cognitions, including expectations and beliefs, by enlisting the clients participation as a colleague and equal rather than one of superior (counsellor) and inferior (client).

The counsellors role is that of teacher and a role model of positive healthy behavior, rather than that of expert, therefore this approach should work well when working with muti-cultural cliental and because of the structured nature of CBT it is a positive approach that bares tangible effective evidence to encourage a client to tackle the presenting problem. Although CBT does not look specifically at a clients past it does help a client to look more realistically at their outdated beliefs or schemas ( I am unloveable or I am worthless) often errors in thinking picked up in childhood and early life.

As counsellors/therapists it is however necessary to have in ones mind and consider client ethnicity during the various phases of therapy, however typically I believe if we are to maintain equality, we do not directly need to address ethnicity or ethnic differences in therapy sessions unless it is clearly part of the presenting problem, but maintaining an awareness to a persons ethnic origin and differences is essential for good practice.

That said, this modality (CBT) would also be extremely useful in highlighting not only unchallenged beliefs and or rules, (typically rigid over inclusive, impossible to attain) but cultural differences, logical errors in thinking picked up in early life that no longer benefit or support the clients desired way of functioning. Because the approach is directive and highly structured it involves asking clients detailed and specific questions about their current feelings, whilst also identifying any automatic thoughts, thus enabling them in becoming ware of how they think about a problem, how it affects them physically and or emotionally and what they can do to alter the outcome. When a client see the sequence clearly change is possible. By encouraging the client to look at particular situations that disturb or upset them important information is elicited so that problems can be clarified from the beginning of therapy with objectives being set accordingly. The highly active, directive and educational nature of cognitive behavior therapy serves to show clients how they disturb themselves and what they can do to change attitudes and or beliefs for themselves that no longer work.

When clients become aware that they are able change themselves feelings of empowerment become evident and rapid progress is made. CBT is, as previously mentioned time limited and because of this clients develop a definite sense of purpose and awareness relating to their progress, coping strategies and developing self-help skills. Curwen et al (2000) stress the importance of empathy in the relationship, Margaret Hough 2nd ed (2002) this is essential to building trust and a genuine rapport given that the work could be extremely challenging.

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