Psychotherapy: Theory, Research, Practice, Training
2006, Vol. 43, No. 4, 506 –517
Copyright 2006 by the American Psychological Association
0033-3204/06/$12.00
DOI: 10.1037/0033-3204.43.4.506
APPLICABILITY OF COGNITIVE–BEHAVIOR THERAPY
WITH AMERICAN INDIAN INDIVIDUALS
LYDIA C. JACKSON
PETER A. SCHMUTZER
Columbia University
University of North Dakota
AMY WENZEL
JOHN D. TYLER
University of Pennsylvania
University of North Dakota
There is little empirical evidence to
support the claim that cognitive–
behavior therapy (CBT) is an especially
suitable treatment for culturally diverse
clients. The purpose of this study was
to compare the applicability of CBT in
a community sample of European
American and American Indian individuals. Participants completed the Cognitive Behavior Therapy Applicability
Scale (CBT–AS), in which they rated
their preference for characteristics consistent with three tenets of CBT. European Americans rated a stronger preference for CBT’s focused in-session
behavior and structured therapeutic
relationship than did American Indians.
Both groups rated the active stance
domain of CBT as mutually acceptable.
On the basis of the findings, several
modifications to CBT for therapists
working with American Indian clients
are proposed for future investigation.
Keywords: cognitive– behavior therapy,
American Indian individuals, Cognitive
Lydia C. Jackson, Department of Psychiatry, Columbia
University; Peter A. Schmutzer and John D. Tyler, Department of Psychiatry, University of North Dakota; Amy Wenzel, Department of Psychiatry, University of Pennsylvania.
The authors wish to thank Pamela A. Hays for her helpful
feedback on earlier versions of this article.
Correspondence concerning this article should be addressed to Lydia C. Jackson, Columbia Anxiety and Traumatic Stress Program, 1775 Broadway, Suite 601, New York,
NY 10019. E-mail: lcj2104@columbia.edu
506
Behavior Therapy Applicability Scale
(CBT–AS)
Cognitive– behavior therapy (CBT) is a widely
adopted, empirically supported psychological
treatment for various types of psychopathology.
The underlying mechanism of CBT involves the
development of strategies to recognize and evaluate maladaptive negative thoughts (cf. Dobson
& Dozois, 2001). Because CBT is focused
strongly on the cognitive attributions characteristic of psychopathology from a Western-majority
cultural perspective, it follows that this therapeutic approach may not be as effective for minorityculture members (Schieffelin, 1985).
On the other hand, numerous clinicians have
identified several features of CBT that may make
it especially suitable for use with clients from
diverse backgrounds. Hays (1995) discussed several such characteristics of CBT. First, it is rooted
in the principle that therapy must be adapted to
meet the needs of the individual, for the purpose
of increasing the appropriateness and effectiveness of therapy for each client. Second, its methods focus on client empowerment. Hays emphasized that respect and understanding related to a
client’s unique situation contribute to a collaborative relationship in which individual and cultural differences are appreciated rather than negated. Third, the attention to conscious processes
and specific behaviors may be particularly appropriate for clients from diverse cultures, especially
when a language barrier is present. This attribute
of CBT also minimizes assumptions that may be
erroneous concerning clients’ underlying manifestations of psychopathology. Finally, the integration of assessment throughout therapy emphasizes therapeutic progress from the client’s
perspective.
Other attributes of CBT that may make it par-
Special Issue: CBT Applicability
ticularly amenable for use when the client and
therapist are from different cultural backgrounds
include (a) a minimal number of theoretical constructs inherent in the approach, (b) present time
orientation, (c) emphasis on action rather than
verbal expressiveness, (d) acknowledgment of
environmental factors, and (e) the partnership
approach (i.e., collaborative empiricism; Casas,
1988). In particular, these attributes minimize
potential errors that may arise when a therapist is
unfamiliar with a client’s cultural background
and customs. They also facilitate discussions that
elicit details regarding idiographic cultural and
social issues that may uniquely affect the client.
Padesky and Greenberger (1995) highlighted
the ways in which culture plays a powerful role in
shaping the automatic thoughts, underlying assumptions, and schemata emphasized in CBT by
providing a compelling example:
A European man with a rapid heart rate may panic following
the thought “I’m having a heart attack.” A Chinese man
experiencing rapid heart rate may panic with the thought “I’m
haunted by an evil spirit who will kill me.” (p. 40)
Similarly, cognitions involving visions of black
dogs and werewolves may elicit panic in a Navajo who is experiencing the same physiological
symptoms. Therapists should be aware that cultural differences exist in all these areas and that
good case conceptualization includes recognizing
and understanding these differences. Padesky and
Greenberger offered several guidelines for adapting CBT for use with multicultural populations.
For example, they suggested that the therapist
should be attuned to cultural influences in the
client’s language and reported behavior. In addition, they recommended that the therapist should
consider the manner in which these influences
affect the conceptualization of the client’s problems and treatment plan. They also encouraged
therapists to educate themselves regarding cultures in which they are providing services, consult with colleagues, and openly discuss culture
with clients, including discussing their own limitations.
Kaiser, Katz, and Shaw (1998) suggested that
the suitability criteria for CBT (Safran & Segal,
1996) may need to be modified for non-European
American individuals. These suitability criteria
are 10 characteristics a client may possess that
would predict a favorable response to CBT-based
interventions. Specifically, these criteria are (a)
accessibility of automatic thoughts (ability to decenter oneself from automatic cognitions and de-
scribe one’s role in making cognitive appraisals),
(b) awareness and differentiation of emotions
(detecting mood fluctuations is necessary for
monitoring automatic thoughts), (c) acceptance
of personal responsibility for change (playing an
active role in one’s own recovery), (d) compatibility with cognitive rationale (valuing aspects of
CBT such as exploring the relation between feelings and thoughts and doing homework assignments), (e) alliance potential: in-session evidence
(potential to form a therapeutic alliance), (f) alliance potential: out-of-session evidence (history
of previous meaningful relationships, including
previous therapy), (g) chronicity of problems (recent onset of symptoms enhances suitability), (h)
security operations (ability to self-explore within
a short-term context), (i) focality (ability to maintain a problem focus), and (j) general optimism
regarding therapy (how hopeful one is that therapy can produce beneficial change). Exactly how
to modify these suitability criteria for varying
cultural groups, however, remains to be determined.
CBT With American Indian Clients
To date, there has been relatively little research
evaluating the efficacy of CBT for different cultural groups. As investigators continue to call for
diversity in CBT training and research (e.g., Safren, 2001), recent studies have emphasized the
contribution of cultural factors in treatment outcome, including the need to study distinct cultural
groups rather than assuming all nonmajorityculture clients will respond similarly to psychotherapy. However, there have been no studies that
have specifically investigated CBT’s effectiveness with American Indian individuals. In spite of
the lack of empirical data, several clinicians have
identified ways in which CBT may be particularly suitable for American Indian clients. For
example, Renfrey (1992) highlighted the manner
in which CBT’s focus on the present, action
orientation, and directiveness are especially useful therapy characteristics. He described how a
present-time focus, provision of concrete skillstraining, and an assertive, directive healer are
therapeutic qualities consistent with American
Indian cultural values.
Renfrey (1992) also proposed that non-Indian
therapists conducting CBT with American Indians should incorporate high levels of cultural
sensitivity to minimize potential therapy-
507
Jackson, Schmutzer, Wenzel, and Tyler
interfering behaviors or assumptions. For example, cultural differences may influence therapy
when the therapist is conducting a functional
analysis of behavior. Because learning histories
may be quite different between Indian clients and
non-Indian therapists, incorrect assumptions regarding typical antecedents and consequences of
behavior may result. In addition, Renfrey proposed that diagnostic classifications may not be
appropriate or culturally relevant. Rapport may
be hard to develop because of a long history of
exploitation by the dominant culture. American
Indian individuals may incorporate longer pause
times in conversation, and jumping in to fill the
silence may be seen as disrespectful; furthermore,
interpreting it clinically may lead to errors in case
conceptualization. Sensitivity to these and other
cultural considerations would enable the development of interventions that are more congruent
with the client’s worldview and cultural practices.
Regardless of the particular theoretical orientation used, several other general considerations
are important to note. In spite of the informal
quality of interpersonal relationships often seen
among Native individuals (Dana, 1993), it has
been suggested that American Indians may assign
a powerful, expert status to non-Indians who are
providing counseling (Herring, 1990). Herring
also emphasized that counselors should be flexible and use whatever appropriate means are
available to attain treatment goals. For instance, a
therapist may wish to incorporate spiritual elements, such as a sweat ceremony, with the assistance of the proper community leaders. Finally,
like other clinicians (e.g., Heinrich, Corbine, &
Thomas, 1990; McDonald, Morton, & Stewart,
1993), Herring stressed the necessity of measuring acculturation. Disparities among individuals
who identify more or less with traditional values
play an important role in the culturally sensitive
provision of CBT.
Fiferman (1989) conducted the only empirical
exploration of CBT acceptability with American
Indian individuals. He created a vignette describing a person with major depressive disorder and
provided college students with treatment rationales for cognitive, behavioral, client-centered,
and traditional Native American therapy. He then
asked his American Indian and European American participants to rate the acceptability of each
therapeutic approach. As he predicted, traditional
American Indian participants rated the client-
508
centered and Native American treatment as more
acceptable than did nontraditional American Indian and European American participants. In contrast, European Americans and more acculturated
American Indians rated cognitive therapy as the
most acceptable mode overall. Clearly, his findings illustrate the impact of an individual’s acculturation status on agreement with traditional
American Indian values and consequent therapy
preferences.
Acculturation may be defined as the degree to
which one culture changes as a result of contact
with other cultures (Berry, Poortinga, Segall, &
Dasen, 2002). With American Indian individuals,
acculturation may be defined as the degree to
which a person adopts majority and tribal cultural
values (Choney, Berryhill-Paapke, & Robbins,
1995). Acculturation is particularly salient given
that strong identification with one or more Indian
cultural groups has been shown to be positively
related to good mental health among American
Indian individuals (LaFromboise & Rowe, 1983)
and that contact with European Americans has
unfortunately resulted in the loss of tribal lands,
indigenous language, and traditional culture (Moran, Fleming, Somervell, & Manson, 1999). Most
studies have described American Indian ethnic
identity in terms of a unidirectional acculturative
process whereby traditional American Indian behaviors are reduced and behaviors more consistent with the majority culture are adopted
(Choney et al., 1995). In the present study, we
define acculturation as the degree to which individuals do not engage in traditional American
Indian ways of life.
In addition to assessing acculturation, it is important for clinicians and researchers to pay particular attention to individual differences among
American Indian clients. Lomay and Hinkebein
(2006) emphasized how important it is for nonNative therapists to be aware of the significant
diversity among different Native groups. The approximately 200 million American Indians in the
United States consist of more than 500 different
Native groups (Dana, 1993) who speak more than
250 different languages (Herring, 1990).
The current study was an investigation of the
perceived applicability of CBT in a community
sample of European Americans and American
Indians. We chose to explore attitudes toward
aspects of CBT because treatment desirability has
been shown to significantly influence outcome
(e.g., Cross-Calvert & McMahon, 1987). More-
Special Issue: CBT Applicability
over, matching clients to specific psychotherapeutic modalities on the basis of suitability criteria is likely to improve therapy effectiveness
(Beutler, Mohr, Grawe, Engle, & MacDonald,
1991) and result in fewer dropouts, stronger compliance, and more overall satisfaction with therapy (Kazdin, 1980).
Although the prospective merits and weaknesses of using CBT with American Indian clients have been described by numerous clinicians,
this is the first study to empirically evaluate
which aspects of CBT may need modification.
We hypothesized that European American individuals would indicate higher levels of agreement
with CBT’s focused in-session behavior, active
stance, and structured therapeutic relationship
than would American Indian individuals. We also
hypothesized that American Indians who were
more acculturated would have scores more similar to those of European Americans than to those
of the American Indians who were less acculturated.
Method
Focus Group
Before any data collection, feedback regarding
the study’s cultural sensitivity was solicited from
a focus group of 10 Northern Plains Indian undergraduate and graduate students. The students
were part of the Indians Into Psychology Doctoral Education program at the University of
North Dakota. Focus group members met with
the principal investigator to discuss the measures
to be used as well as the study’s design. The aim
of conducting the focus group meeting was to
gather information to construct an appropriate
research design that would maximize cultural
sensitivity and relativity (Hughes & DuMont,
1993). The University of North Dakota student
focus group indicated that the study design and
materials appeared culturally acceptable to them.
Participants
Ninety-five American Indian individuals were
recruited from the annual Time-Out Wacipi PowWow held at the University of North Dakota in
April 2002. After obtaining permission from the
University of North Dakota Indian Association,
investigators set up a table at the pow-wow in
exchange for providing the association demo-
graphic information regarding pow-wow attendants. There were no inclusion or exclusion criteria other than being at least 18 years of age. All
participants were informed that participation was
voluntary and they might withdraw at any time.
They received $5 for completing the packet of
questionnaires.
European American individuals from the community were recruited from the Grand Forks
Blues Festival, held in June 2002. We received
permission from the event coordinator for investigators to set up a table and recruit individuals in
the same manner they were obtained during the
Time-Out Wacipi Pow-Wow. Additional community members were recruited through area advertisements in the Grand Forks Herald newspaper and on a local TV channel. They also
received $5 for completing the packet of questionnaires. There were no inclusion or exclusion
criteria other than being at least 18 years of age.
Equal numbers of American Indian and European American individuals (ns ⫽ 41) were
matched on the basis of their age and gender
equivalence as the final sample of individuals for
analyses. The mean age of the American Indian
group was 35.1 years (SD ⫽ 12.2), and the mean
age of the European American group was 35.6
years (SD ⫽ 12.3). Both groups included 13 men
and 28 women. The Hollingshead Socioeconomic
Status Index (Haug & Sussman, 1971) was computed for both groups, using the mother’s and
father’s educational level and type of employment. The American Indian group had a total
mean socioeconomic status index score of 38.0
(SD ⫽ 13.5), and the European American group
had a mean score of 38.7 (SD ⫽ 12.6), which was
not significantly different.
Measures
In addition to the demographic questionnaire,
participants completed the Orthogonal Cultural
Identification Scale (OCIS; Oetting, Swaim, &
Chiarella, 1998). The OCIS is a six-item instrument that measures perceptions of and behaviors
consistent with an American Indian way of life
and has been used in numerous studies with
American Indian individuals (e.g., Bryant & LaFromboise, 2005). The OCIS has been shown to
have good construct validity, with scores significantly correlated with self-esteem and family
relationships. Oetting et al. reported a coefficient
alpha (Cronbach, 1951) of .80. The coefficient
509
Jackson, Schmutzer, Wenzel, and Tyler
alpha for American Indian affiliation in the
present study was .97. We scored the OCIS such
that higher scores on the American Indian probe
items reflected higher degrees of acculturation,
that is, lesser identification with traditional Native American values and behaviors.
To assess participants’ perceptions of cognitive therapy parameters, the Cognitive Behavior
Therapy Applicability Scale (CBT–AS; Jackson,
Schmutzer, & Wenzel, 2002) was administered.
The CBT–AS is a self-report measure that was
developed by the principal investigator to examine both suitability criteria and client preferences
for aspects of CBT. Participants responded to the
probe statement “Assume that you decided to
seek therapy or counseling because of emotional
difficulties (like feeling sad) or things you might
be going through (like the loss of a loved one)”
and rated their preferences for 24 therapy attributes via a Likert-scale format (where 1 ⫽
disagree strongly and 5 ⫽ agree strongly). These
characteristics are based on Beck’s (1995) principles of CBT, suitability criteria outlined by
Safran and Segal (1996), and specific constructs
related to using CBT with ethnically diverse individuals (e.g., Casas, 1988).
The CBT–AS is composed of three factor
scales: Focused In-Session Behavior, Active
Stance, and Structured Therapeutic Relationship. The Focused In-Session Behavior scale
assesses the degree to which participants agree
that therapy should involve linear analyses of
how thoughts cause feelings. The Active
Stance scale measures desirability for a client’s
active participation in and out of session (such
as completing homework assignments). The
Structured Therapeutic Relationship scale assessed agreement with personal responsibility
for change as well as a clearly defined and
business-oriented relationship between the
therapist and client. Although measures of concurrent, discriminant, and predictive validity
for the CBT–AS have not yet been obtained,
qualitative measures of face validity are available. Eighty-two percent of the participants in
the standardization sample stated that the items
were clear, and 92% stated that the items were
understandable. The CBT–AS has demonstrated good internal reliability, with an overall
coefficient alpha of .84 (Jackson et al., 2002).
The coefficient alphas for the three factor
scales with the participants in this study were
.87 for Focused In-Session Behavior, .78 for
510
Active Stance, and .81 for Structured Therapeutic Relationship.
Data Analysis
We hypothesized that European American individuals would indicate higher levels of agreement with treatment characteristics that are part
of a CBT therapeutic framework than would
American Indian individuals. We also hypothesized that American Indians who were more acculturated would have scores more similar to
European Americans than would the American
Indians who were less acculturated. To test the
first hypothesis, a discriminant analysis procedure (Green, Salkind, & Akey, 2000) was used to
determine if CBT–AS scores would predict group
membership (i.e., European American or American Indian). An additional discriminant analysis
procedure, including post hoc analyses of variance among the three groups, tested the second
hypothesis that American Indians who were more
acculturated would have CBT–AS scores more
similar to European American participants.
Results
Scores on the Focused In-Session Behavior
scale of the CBT–AS (CBT–AS1), the Active
Stance scale (CBT–AS2), and the Structured
Therapeutic Relationship scale (CBT–AS3) were
used as the predictors in a discriminant analysis
procedure to determine whether there were differences between the American Indian and European American participants in terms of CBT applicability. Descriptive data for the CBT–AS
factor scale scores are presented in Table 1.
TABLE 1. Descriptive Data for the Cognitive Behavior
Therapy Applicability Scale (CBT–AS) Scores
Group and measure
American Indian
CBT–AS1
CBT–AS2
CBT–AS3
European American
CBT–AS1
CBT–AS2
CBT–AS3
M
SD
Min
Max
26.32
27.83
28.93
7.10
7.21
7.71
7.00
8.00
8.00
35.00
40.00
40.00
31.00
29.56
33.83
3.18
4.33
3.71
24.00
19.00
26.00
35.00
40.00
40.00
Note. CBT–AS1 ⫽ Focused In-Session Behavior scale
(range ⫽ 7–35); CBT–AS2 ⫽ Active Stance scale
(range ⫽ 8 – 40); CBT–AS3 ⫽ Structured Therapeutic
Relationship scale (range ⫽ 8 – 40).
Special Issue: CBT Applicability
The overall Wilks’s lambda was significant,
⌳ ⫽ .8, 2(3, N ⫽ 82) ⫽ 18.7, p ⬍ .001, indicating that the predictors were able to differentiate between the two groups of participants. The
within-groups correlations between the predictors
and the discriminant function, as well as the
standardized weights, are given in Table 2.
On the basis of these coefficients, the Focused
In-Session Behavior scale showed the strongest
relation with the function, although the Structured Therapeutic Relationship scale also showed
a strong relation. The Active Stance scale showed
the weakest relation with the function. On the
basis of the contents of the items in CBT–AS1
and CBT–AS3, this function may be labeled CBT
structured behavior and relationship. The means
on the discriminant function are consistent with
this interpretation. The European Americans had
higher mean scores (M ⫽ 0.5) than the American
Indians (M ⫽ ⫺0.5) on the CBT structured behavior and relation dimension.
This function was able to classify correctly
72.0% of the individuals. To account for chance
agreement, a kappa coefficient was computed to
be .4, a moderate value that is statistically greater
than chance (p ⬍ .01). To assess how well the
classification procedure would predict in a new
sample, the leave-one-out technique was used.
The percentage of individuals accurately classified was 69.5%. Finally, the effect size for this
discriminant function was calculated to be 0.2.
Acculturation Levels and CBT Applicability
A cultural affiliation measure was obtained for
the American Indian participants using total
scores for the American Indian probe items from
the OCIS. As previously noted, higher numbers
TABLE 2. Standardized Coefficients and Correlations of
Cognitive Behavior Therapy Applicability Scale
(CBT–AS) Scores
CBT–AS
Correlation
coefficients
with
Discriminant
Function 1
Standardized
coefficients
for
Discriminant
Function 1
CBT–AS1
CBT–AS2
CBT–AS3
.83
.28
.79
.80
⫺.72
.69
Note. CBT–AS1 ⫽ Focused In-Session Behavior scale;
CBT–AS2 ⫽ Active Stance scale; CBT–AS3 ⫽ Structured Therapeutic Relationship scale.
on the OCIS indicate the individual is more acculturated, or less traditionally Indian. The American Indian participants’ mean score was 8.6
(SD ⫽ 3.4); scores ranged from 6 to 16. On the
basis of the sample’s frequency distribution, a
mean split was used such that persons with OCIS
scores between 6 and 8 would be considered low
in cultural acculturation, or more traditional (n ⫽
12). Persons with OCIS scores of 9 and above
were considered high in acculturation, or less
traditional (n ⫽ 26). An additional discriminant
analysis procedure was conducted to examine the
ability of the CBT–AS subscales to predict membership in the three groups: European Americans,
high-acculturated American Indians, and lowacculturated American Indians. The overall
Wilks’s lambda was significant, ⌳ ⫽ .7, 2(3,
N ⫽ 79) ⫽ 22.5, p ⬍ .001, indicating that the
predictors were able to differentiate among the
three groups. The residual Wilks’s lambda was
not significant, ⌳ ⫽ 1.0, 2(3, N ⫽ 79) ⫽ 0.4,
p ⫽ .83, indicating that the predictors could not
differentiate significantly among the three groups
after partialing out the effects of the first discriminant function. Because only the first test was
significant, only the first discriminant function
was interpreted. The within-groups correlations
between the predictors and the discriminant function, as well as the standardized weights, are
given in Table 3.
Similar to previous results, these coefficients
indicate that the first CBT–AS scale shows the
strongest relation with the function, although the
third CBT–AS scale also shows a strong relation.
Again, CBT–AS2 shows the weakest relation
with the function. On the basis of the contents of
the CBT–AS1 and CBT–AS3 items, this function
may again be labeled CBT structured behavior
and relationship. The means on the discriminant
function are also consistent with this interpretation. The European Americans had higher mean
scores (M ⫽ 0.5) on the CBT structured behavior
and relationship dimension than the highacculturated American Indians (M ⫽ ⫺0.2), who
in turn had higher mean scores than the lowacculturated American Indians (M ⫽ ⫺0.7).
This function correctly categorized 59.5% of
the individuals into one of the three groups. To
account for chance agreement in this prediction, a
kappa coefficient was calculated at a value of .35,
a modest value that is statistically greater than
chance (p ⬍ .01). To assess how well the classification procedure would predict in a new sample,
511
Jackson, Schmutzer, Wenzel, and Tyler
TABLE 3. Standardized Coefficients and Correlations of
Cognitive Behavior Therapy Applicability Scale
(CBT–AS) Scores Incorporating Acculturation Status
CBT–AS
Correlation
coefficients
with
Discriminant
Function 1
Standardized
coefficients
for
Discriminant
Function 1
CBT–AS1
CBT–AS2
CBT–AS3
.84
.26
.76
.89
⫺.73
.59
Note. CBT–AS1 ⫽ Focused In-Session Behavior scale;
CBT–AS2 ⫽ Active Stance scale; CBT–AS3 ⫽ Structured Therapeutic Relationship scale.
the leave-one-out technique was used. The percentage of individuals accurately classified was
53.2%.
Acculturation Status and Similarity to European
American Individuals
Follow-up univariate one-way analyses of
variance were conducted to determine whether
the three groups would perform differently on the
three CBT–AS scales. Results are presented in
Table 4. The data indicate that the three groups
had significantly different scores on the Focused
In-Session Behavior (CBT–AS1) scale and the
Structured Therapeutic Relationship (CBT–AS3)
scale. For significant outcomes, a post hoc
Tukey’s honestly significant difference analysis
was conducted to further understand how the
three groups varied. The low-acculturated American Indian individuals scored differently than
did the European American individuals on the
CBT–AS1 (p ⬍ .001) and the CBT–AS3 (p ⬍
.001). In contrast, there were no significant differences between the high-acculturated American
Indian individuals and individuals in either of the
other two groups. In terms of CBT applicability,
the high-acculturated American Indian group was
more similar to the European American group
than to the low-acculturated American Indian
group.
Discussion
Findings from the CBT–AS allow for a determination of what specific CBT components may
be more or less applicable for American Indian
clients. The European American group rated the
Focused In-Session Behavior scale as more ap-
512
pealing than did the American Indian group. This
factor scale contains items that specifically target
CBT components outlined by Beck (1995) in
which the therapist encourages the client to uncover the relation between thoughts and feelings,
vis-á-vis the client’s specific problems. The specific and linear focus that is part of CBT could be
unappealing to a Native culture that is traditionally less achievement directed than European
American culture. In their analysis of the provision of mental health services in a reservation
setting, Tyler, Cohen, and Clark (1982) noted that
majority-culture members tend to explain behavior by emphasizing a linear, logical approach,
whereas Native individuals tend to explain behavior in terms of harmony with a natural order.
The second CBT–AS factor scale, Active
Stance, was rated as similarly acceptable by both
American Indians and European Americans. This
scale measures the respondent’s desire for active
participation both in and out of session. The items
on this factor scale relate to therapeutic tasks,
such as activity scheduling and homework completion. The items also reflect the time-limited
nature and present-time orientation of CBT. The
mutual desirability of the active stance domain of
CBT between both American Indian and European American participants is consistent with the
assertion that a present-time orientation (Casas,
1988) and active orientation (Renfrey, 1992) may
be especially appealing to American Indian cliTABLE 4. Analysis of Variance Results for European
Americans and American Indians With High and Low
Cultural Acculturation
CBT–AS
CBT–AS1
Between groups
Within groups
Total
CBT–AS2
Between groups
Within groups
Total
CBT–AS3
Between groups
Within groups
Total
Sum of
squares
df
Mean
square
539.97
2,226.87
2,766.84
2
76
78
269.99
29.30
9.21*
65.54
2,709.17
2,774.71
2
76
78
32.77
35.65
0.92
545.22
2,760.86
3,306.08
2
76
78
272.61
36.33
7.50*
F
Note. CBT–AS ⫽ Cognitive Behavior Therapy Applicability Scale; CBT–AS1 ⫽ focused in-session behavior;
CBT–AS2 ⫽ active stance; CBT–AS3 ⫽ structured therapeutic relationship.
*
p ⬍ .001.
Special Issue: CBT Applicability
ents. This finding is also consistent with observations by various clinicians (e.g., Hays, 1995)
that these particular aspects of CBT might make
it a viable therapeutic approach for some minority individuals.
The acceptability of CBT’s active stance contradicts Fiferman’s (1989) finding that traditional
American Indian college students preferred Native American and client-centered therapy. However, it is important to note that in Fiferman’s
study, the participants were presented with treatment rationales, not specific components of each
type of psychotherapy. Furthermore, the students
were presented with a vignette describing a person with depression and were asked to choose
which treatment they found most acceptable. It is
not surprising that traditional American Indian
individuals would not choose cognitive or behavioral treatments, as they would not attribute the
etiology of depression to cognitive or behavioral
factors. Traditional individuals would be more
likely to attribute depressive symptoms to causes
such as disharmony. This is compatible with
present findings in which American Indian individuals did not agree that therapy should involve
doing linear analyses of how thoughts cause feelings. Taken together, these results suggest that
American Indian individuals might endorse the
CBT components of activity scheduling, homework completion, and provision of short-term,
present-focused treatment while not agreeing
with the rationale of how CBT works. This has
important implications for how clinicians present
the treatment framework for CBT to American
Indian clients.
Finally, a structured therapeutic relationship
was rated as more desirable by European Americans than by American Indians. Some of the
items on this factor scale were constructed to
represent a client’s acceptance of personal responsibility for change (cf. Safran & Segal,
1996). The differential levels of desirability for
personal agency may not be surprising given traditional Native beliefs of interdependence (Dillard & Manson, 2000). Other items on the Structured Therapeutic Relationship scale pertain to
the limited, business-oriented relationship between the therapist and client within the CBT
paradigm. This relatively structured and restricted professional relationship between patient
and healer may be a foreign concept to many
American Indians. For example, it is at times
necessary for the clinician to conduct therapy
sessions at the client’s home in the provision of
psychotherapy in a rural setting (Willis, Dobrec,
& Bigfoot Sipes, 1992). Making home visits is
not something that majority-culture members
typically associate with psychotherapy. In addition, American Indians have long had their own
mental health services in the form of spirit healers, medicine people, friends, and kin (Trimble &
Fleming, 1989), community members usually
well known to the client outside of a service role.
The conventional discrete therapeutic relationship espoused in majority culture may violate
Natives’ historical expectations of the healing
relationship.
Often these value differences between American Indians and majority-culture members are
related to varying levels of acculturation (McDonald et al., 1993). Fiferman (1989) found that
the European American and more acculturated
American Indian college students both rated cognitive therapy as their treatment of choice when
presented with the choices of cognitive, behavioral, client-centered, and traditional Native
American therapy. However, more traditional
Native students chose traditional Native American therapy as their preferred treatment modality.
When the current sample was divided into high
and low acculturation status on the basis of a
mean split on OCIS scores, comparable results
were obtained. Specifically, significant findings
on the first and third CBT–AS factor scales were
due to differences between European Americans
and more traditional American Indians, whereas
the more acculturated American Indians did not
differ significantly from the European Americans
on any of the CBT–AS scales. This suggests that
highly acculturated Native individuals may respond similarly to European Americans regarding their preferences for characteristics of CBT.
Results from the Structured Therapeutic Relationship scale suggest that a nonclinical sample
of American Indian individuals may prefer a therapy in which personal agency is not emphasized.
In contrast, expectations for a CBT client are that
she or he be dedicated and active (Safran &
Segal, 1996). Kaiser, Katz, and Shaw (1998)
noted that American Indians may demonstrate an
external locus of control in problem solving,
which could come across as passivity or treatment noncompliance to a naı̈ve clinician. The
potentially negative interpretation of such an observation might be averted if the clinician is able
513
Jackson, Schmutzer, Wenzel, and Tyler
to implement a more culturally appropriate type
of CBT.
CBT for American Indian Clients: Implications
for Future Study
Clinicians such as Trimble and LaFromboise
(1985) have speculated as to whether it is possible to modify conventional therapeutic techniques to make them more amenable for traditional American Indian clients. On the basis of
both the present findings and recommendations
offered by clinicians who have provided mental
health services to this population, the following
suggestions are offered for therapists to consider
and for researchers to empirically examine.
First, clinicians might limit the extent to which
clients are encouraged to label their thoughts and
feelings in an abstract manner. The American
Indians in this study rated talking a lot about their
thoughts and feelings as less desirable than did
European Americans. Dillard and Manson (2000)
noted that if a Native client is asked to identify
and label his or her feelings, little information
may be obtained, and confusion may result. Traditionally oriented American Indians are generally not socialized to talk about their thoughts and
feelings (D. W. Sue & Sue, 1999), and affect is
typically expressed in terms of contextual and
interpersonal difficulties (Manson, 1995; T. Makowski, personal communication, March 2003).
It is suggested that clinicians first inquire about
the client’s current social world and then ask how
particular difficulties may be affecting him or her
in an emotional way (Dillard & Manson, 2000).
Second, linear causality and cause-and-effect
relationships might be deemphasized, especially
with regard to the etiology of the client’s pathology and in terms of how the client should
problem-solve solutions. Results from the study
indicated that American Indians rated learning
how thoughts cause feelings as a less desirable
focus of therapy than did European Americans.
Native individuals may conceptualize illness as
an imbalance among the mind, body, and spirit or
as stemming from spiritual causes (McDonald et
al., 1993). McDonald et al. also stated that Natives tend to think holistically rather than linearly.
Rather than focusing on linear cause-and-effect
analyses, therapists might explore the reciprocal
relation between events in the client’s world and
his or her current level of distress.
Third, the clinician may maintain CBT’s stated
514
focus on the present and emphasize logistical
problem-solving or solution-focused skills. Therapy that involves an active stance domain and
focus on the present was rated as desirable by
both American Indians and European Americans.
This suggestion is consistent with anecdotal reports (e.g., Tyler et al., 1982) that American
Indians tend to view mental health services as
more of a crisis management intervention than do
majority-culture members. Because fewer than
half of urban American Indians return after the
initial contact (S. Sue, 1977), it is even more
important to focus on the client’s immediate
needs.
Fourth, the clinician should consider being
flexible regarding the time, length, and frequency
of treatment sessions. Relative to the European
American participants, the American Indian participants did not agree that meeting with the therapist for one hour each week was a particularly
acceptable way to conduct therapy. The overall
length of therapeutic interventions with Native
individuals may differ from the standard number
of CBT sessions. For example, at the Albuquerque, New Mexico, Indian Health Services Hospital, the average length is three sessions (S.
McArthur, personal communication, October
2002). According to Dillard and Manson (2000),
if therapists can allow for longer individual sessions on an as-needed basis (e.g., if there has
been a suicide in the community), premature
dropout may be prevented. Dillard and Manson
also indicated that some Native individuals are
not able to attend weekly consecutive sessions
because they may need to first meet basic needs
such as finding transportation. Furthermore, the
traditional American Indian presenting for therapy may view the 50-min therapy session scheduled for a specific time as an arbitrary constraint,
as they may perceive their appointment as being
“sometime today” (McDonald et al., 1993, p.
450).
Fifth, community members and family or
friends should be integrated into the treatment
approach, wherever appropriate. In the present
study, American Indians indicated a stronger
preference for including family and friends in
therapy than did the European Americans.
Trimble and Fleming (1989) recommended that
therapists respect the traditional social and network processes of many Indian people by involving kin members in therapy. This can be especially difficult for non-Native therapists, who
Special Issue: CBT Applicability
must balance a strong sense of ethics in respecting confidentiality with the culturally appropriate
incorporation of friends and extended family
members.
Sixth, personal autonomy in the change process might be minimized, and efforts to maximize
whatever environmental sources of strength the
client endorses should be implemented. On the
CBT–AS, European Americans agreed more with
the notion that they would have a very active role
in feeling better than did the American Indians.
This is consistent with the observation that with
American Indian clients factors such as familial
patterns, peer-group orientations, and tribal and
ethnic identification are both etiological factors
and important resources for treatment success
(Trimble & LaFromboise, 1985). Again, this can
be especially difficult for non-Native therapists
who are often taught to value and promote a
strong internal locus of control in their clients.
Limitations
Several limitations of this study should be acknowledged. The participants were community
members recruited from a pow-wow, from a
blues festival, and through radio and newspaper
advertisements. Thus, there may be a selection
bias in this sample given the self-referral nature
of the population. Another limitation of the sample is that the American Indian participants were
largely from Northern Plains tribes, so it is not
possible to conclude that these results apply to
American Indians in general. Furthermore, even
among Northern Plains Indians, individual differences must be taken into account.
An additional consideration is the comparability of the two cultural samples. An indeterminable number of psychosocial and biological factors may limit the comparability of a pow-wow
sample of American Indians with European
Americans recruited through other community
resources. This comparability of samples in terms
of distress and disability, diagnosis, demographic
and social characteristics, and manner of recruiting is one that plagues the multicultural research
community as a whole (Draguns, 1995). Nonetheless, extensive efforts were made to maximize
the similarity of these two groups: They were
matched on age and gender, no differences were
found on socioeconomic status, and a
community-sponsored music festival is one of the
few European American traditions that might
share some characteristics with an American Indian pow-wow.
Another point involves the use of self-report
measures in this study. It is possible that the
participants indicated various preferences on paper but would react in a different way interpersonally. This might be particularly problematic
with the American Indian participants, as some
clinicians have suggested that these individuals
sometimes agree with the therapist, then behave
differently outside of the session (Swinomish
Tribal Mental Health Project, 1991). Thus, demand characteristics may be especially salient in
this group.
Finally, results from the CBT–AS administration and previous literature (e.g., Renfrey, 1992)
suggest that certain aspects of CBT could be
modified to maximize cultural acceptability to
American Indian clients. Although cross-cultural
researchers have urged clinicians to modify CBT
when working with minority clients, modified
versions may not be equivalent to the formulation
to which controlled treatment outcome studies
adhere. The efficacy of CBT may then have to be
revalidated in these populations.
On the other hand, component analyses of the
specific mechanisms by which CBT elicits therapeutic improvement have only begun to be examined, and altering certain characteristics of
CBT to make the approach more applicable for
American Indians may not decrease CBT’s effectiveness. For instance, Jacobson and colleagues
(1996) found that behavioral activation alone was
as efficacious as the combination of behavioral
activation and cognitive techniques addressing
maladaptive automatic thoughts and core schemata in a sample of 152 individuals diagnosed
with major depression. This equivalency in treatment gains was maintained at 2-year follow-up
(Gortner, Gollan, Dobson, & Jacobson, 1998).
Given that American Indians rated behavioral
activation components of CBT as suitable treatment maneuvers, it is possible that CBT adapted
for this group will be found efficacious. Whether
culturally modified versions of CBT are “similar
enough” remains to be empirically determined.
Conclusion
Differential scores on the CBT–AS between
American Indians and European Americans imply that clinicians treating ethnic minorities may
wish to carefully monitor their client’s accept-
515
Jackson, Schmutzer, Wenzel, and Tyler
ability of the treatment approach and rationale
they choose to implement. In fact, Parron (1982)
included the lack of culturally acceptable treatment as one of the four main reasons minorities
underuse mental health services. This is important for American Indians in particular, as research has indicated that American Indian clients
are more likely to terminate treatment after the
first psychotherapy session than are European
American clients (Norton, 1999). Johnson and
Cameron (2001) added that not only is very little
known about help-seeking behavior in this group,
but also that an American Indian client and a
majority-culture therapist may have quite different ideas about the etiology of mental illness,
how each should act, and how the problem should
be treated. These researchers also reported that
there are no mental health outcome studies of
American Indians. Given the lack of information
concerning the provision of psychological services to American Indian clients, the present
study is a first step toward finding effective
modes of psychotherapy for this cultural group.
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