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). 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