A CULTURALLY-ADAPTED COGNITIVE
BEHAVIOR THERAPY FOR CHILDREN
Interview with Shin-ichi Ishikawa
Dr. Shin-ichi Ishikawa is a professor at the Faculty of Psychology at Doshisha University, (Kyoto, Japan) and a member of the executive board of the Asian Association for Cognitive Behavioral Therapy. He received his bachelor's degree from Waseda University and his doctorate in health sciences from Hokkaido University. He also attended Swarthmore College as a Fulbright scholar and was a visiting professor at Macquarie University. His research has focused on the clinical psychology of children and adolescents, especially on treatment, prevention and psychopathology. He has received several awards from distinguished organizations including, the Japanese Psychological Association, the Japanese Association for Cognitive Behavioral Therapy, and the Japanese Association for Guidance Science.
The subject of your presentation at the upcoming 13th International and 18th National Congress of Clinical Psychology is the cultural adaptation of cognitive behavioral therapy for anxiety in children. To set the scene regarding this subject, what is understood by the approach of cultural adaptations of psychological therapies? When and why did the first proposals arise in this field and what is the current situation in this line of research?
SI: As the readers know well, cognitive behavior therapies have been recognized as effective psychosocial treatments based on outcome studies. However, the research focused on population from Western cultures exclusively, as a result, there is little to no attention to cultural influences related to ethnicity, religion, sexual orientation, disability, or social class (Iwamasa & Hays, 2019). It is because that cultural adaptation is inevitable for implementation of evidence-based psychosocial treatments. Cultural adaptation is the systematic modification of an evidence-based treatment or intervention protocol to consider language, culture, and context in such a way that is compatible with the client’s cultural patterns, meanings, and values (Tanaka-Matsumi, 2011).
The concept of cultural adaptation appeared in the healthcare literature from 1990s (Saha, Bech, & Cooper, 2008), although cultural mismatches in delivering mental health services had already reported. For example, Sue (1998) articulated in American Psychologists that cultural competency which consists of triad corresponding, such as ethnic, services, cognitive matches, would be essential in psychotherapies. In addition, Forehand & Kotchick (1996) issued a wake-up call for behavioral therapists that they should be more sensitive to cultural context when providing parent training. Since then, several theoretical models have been proposed for cultural adaptation. Now, given the globalization for the society, cultural adaptation is practically required to all clinicians, especially when they adapt a cognitive behavior therapy to their client who comes from underrepresenting culture in their context of clinical practice.
With regard to the fact that the studies, the psychological treatment protocols and the recipients of these interventions are centered on a specific culture, what risks are involved in applying them to other groups outside the cultural context for which they were designed?
SI: Regardless of cultural diversity, functional communication must be fundamental for cognitive behavioral approaches. Cultural adapted treatments focus not only on improving therapeutic outcomes, but also to increasing client engagement, knowledge and buy-in of treatment processes and methods, consumer satisfaction, reducing premature dropout, and improving therapeutic relationship (Hwang, 2016). Clinicians should be mindful that cognitive behavioral therapies include flavors from Western cultures inherently because they have been developed in those cultural background. Here, I would like to take up two typical examples of cultural adaptation for Asian population. First, Asian clients tend to somatize their emotional symptoms more than those from Western cultural backgrounds which places greater emphasis on talking about problems and expressing oneself verbally (Chun et al., 1996). Second, stigma of mental health and even its treatment are prevailing among Asian countries. Therefore, it typically takes more time for Asian clients to talk their emotional difficulties via open and clear verbal communications. As I’ll mention later, similar caution would be necessary for clinicians when working with children and adolescents from Asian cultural backgrounds.
Taking into account the different studies that have adapted these psychological treatments to minority groups or cultures other than the Anglo-Saxon one, what results have they found? Is it better to apply culturally adapted therapies in these groups or the original, non-adapted therapy?
SI: Several meta-analyses have supported efficacy of cultural adapted psychosocial treatments. Griner & Smith (2006) conducted the first meta-analysis for cultural adapted mental-health interventions. The study integrated 76 studies and found a medium average effect size (d = 0.45). Especially, interventions provided with groups of same-race participants (d = 0.49) were more effective than interventions provided to groups consisting of mixed-race participants (d = 0.12). A subsequent meta-analysis focusing on refining criteria also found a moderate effect-size (d = 0.46; Smith et al., 2011). Moreover, a meta-analysis for direct comparison between adapted and unadapted treatments showed that culturally adapted psychotherapies were superior to unadapted bona fide psychotherapies (d = 0.32; Benish et al., 2011). Finally, Hall et al. (2016) integrated previous 11 meta-analyses that have been already published with 13,998 participants in 78 studies. The overall effect size supported efficacious of culturally adapted interventions over other conditions (g = 0.67) as well as when comparing with unadapted versions of equivalent interventions (g = 0.52). Overall, we could conclude that evidence has demonstrated efficacy and effectiveness of culturally adapted treatments.
One of the aspects that have received the most attention regarding the cultural adaptation of cognitive-behavioral therapy to Asian contexts in adults has to do with the interdependence of Asian cultures versus the focus on social contexts of cognitive-behavioral therapy. Could you explain this problem to us? What other peculiarities are there for psychological intervention in Asian contexts that are not usually considered from an Anglo-Saxon or European perspective?
SI: Although Asian society including Japan is generally considered as an interdependent society, it needs effortful discussion how the context might affect implementation of cognitive behavioral therapies. Our studies suggested that correlation between independent and interdependent self-construal was much stronger in the Japanese adolescents than those from UK while the linear effects of self-construals and social support on psychopathological symptoms did not differ between two countries (Essau et al., 2013). Considering concepts of independent and/or interdependent could be evaluated based on each cultural norm, the mechanism of effects must be complicated. For example, according to the guideline of treatment trials for child and adolescent anxiety disorders (Creswell et al., 2020), whereas administering independent child and parent diagnostic interviews is recommended, joint parent and child interviews might be more acceptable given the social norm of Japanese society for consultation with health professionals (Ishikawa et al., 2019).
Somatization and stigma which I discussed before should be considered at least when psychosocial interventions are introduced. Clinicians from Western cultural context might misunderstand that clients from Asian heritage backgrounds have less-motivated or show less-engagement when they are reluctant to talk their symptoms as emotional expression. Rather, the passive attitude to authorities might represent implication of respect to the people (Hwang, 2016). Given their cultural norm, it takes more time for them to accept such types of conversations and clinicians should appreciate the way of communications attentively, especially at the first few sessions.
According to your line of investigation, the analysis of the scientific evidence on cognitive behavioral therapy for anxiety in the child-youth population, what are the peculiarities in terms of cultural biases? What role does the cultural context play in these results and what implications does it have?
SI: Although a meta-analysis by Hall et al. (2016) has supported efficacy of cultural adapted psychotherapies, a limitation should be noted: the evidence for children and adolescents from Asian cultural heritage is scarce. Although 27 studies focusing on youth were included in the meta-analysis, only three studies from Asian population were included. Besides the systematic review, the scientific evidence of psychosocial interventions for ethnic minority youth in USA are available in Journal of Clinical Child & Adolescent Psychology (Huey & Polo, 2008; Pina, Polo, & Huey, 2019). Again, while efficacy of CBT for Hispanic/Latino with anxiety disorders was supported, no studies were found for population from Asian cultural heritage.
To fill the gap, we developed the Japanese Anxiety Children/Adolescents Cognitive Behavior Therapy program (JACA-CBT) and conducted the first randomized controlled trial for Japanese children. We found a significant difference between the CBT and wait-list condition at post-treatment, specifically 50 % of participants in the treatment condition were free from their principal diagnoses compared to 12% in the wait-list condition (Ishikawa et al., 2019). Therefore, cognitive behavior therapies can be efficacious for anxiety disorders in children and adolescents universally, however it is premature to detect mediators or moderators due to lack of clinical trials. Specifically, we could not reach a consensus how a culturally adapted treatment for anxious youth works and for whom the modified intervention is required in each cultural context.
Although the need to carry out these cultural adaptations to improve the efficacy of interventions has been recognized in the scientific literature, do we have evidence-based protocols to carry out this process with guarantees? Currently, what is the most recommended methodology that ensures that the essential elements of the original protocol are preserved? What phases does it involve?
SI: Higa-McMillan et al. (2016) reviewed research on treatment for children and adolescents with anxiety disorders for a half century. According to the review, 145 of 165 studies (87.9%) included exposure as an active therapeutic element. Moreover, the within effect size of exposure was large (1.05) even when the component was extracted from integrated treatment approach as cognitive behavioral therapies (1.19). Considering that the main component of integrated CBT programs was also exposure-based techniques, exposure has been considered as an essential component for children and adolescents with anxiety disorders. Our program, the JACA-CBT, also emphasizes that therapists should set as many opportunities as to engage in gradual in vivo exposures in sessions as well as homework. In addition, in terms of components, our program is quite comparable with the previous evidence-based programs which were developed in Western culture. Therefore, the main issues here are not which components should be complied in the program, but how to express the components to the specific population.
Specifically, in your line of research, in which you have adapted cognitive behavioral therapy for anxiety in Japanese children, what elements or details of the original protocol have been considered essential for the adaptation to this context? To what extent have these modifications resulted in an improvement in the efficacy of the intervention in the case of your study?
SI: Again, please let me clarify that the components of our program are comparable with previous programs in Western countries. The JACA-CBT has eight sessions and includes psychoeducation, cognitive restructuring, anxiety hierarchies, relaxation, and exposure (Ishikawa et al., 2019). However, the program has been adapted to be specifically relevant to Japanese children and families.
There are two major avenues for cultural adaptation. The first is top-down approach in which an existing intervention for one group is modified for application to another group and the second is a bottom-up approach which is developed an original protocol within a particular cultural context to address culturally specific concerns (Hwang, 2016; Hall et al., 2016). Although a bottom-up approach is important and indispensable for cultural adaptation, it is not sensible to emphasize exclusive domestic production of psychosocial interventions ignoring the current evidence-based interventions. Thus, an approach that capitalizes on existing evidence-based practices may prove more practical. Therefore, we applied an innovative bidirectional approach, one that includes both top-down and bottom-up approaches and aims to develop a novel treatment that is derived from previous studies but not a simple translation of previous manuals (Ishikawa et al., 2019).
As a result, the treatment was modified through both context and content cultural adaptations for a decade. First, the JACA-CBT addressed six contextual adaptations; population, personnel, setting, format, dosage, and procedure. For example, parents were in the same room as their child receiving the explanation and discussing each topic, whereas parents and children are typically seen separately in Western countries. In addition, treatment length was shorter - eight sessions - compared with 16 sessions for Coping Cat (e.g., Kendall, 1994). Second, the JACA-CBT tailored materials as well as adjusting elements and time-management from content adaptation. For example, culturally specific illustrations and acronym were prepared, the habituation model of anxiety was compiled to encourage the exposure session, vignettes were associated with socially relevant situations given that most clients referred to the clinic had social anxiety disorder, and relaxation was included as a compulsory topic considering that Asian individuals tend to show their anxiety as physical symptoms.
In your opinion, is it possible to create evaluation tools and intervention protocols for cross-cultural use? What steps should be taken in this field to avoid cultural biases in the research?
SI: We started new research project corroborating with Macquarie University, Sydney, Australia. We developed an observational coding system to examine behaviors exhibited by child, parent, and therapist during CBT sessions, named the Cross-cultural Behavioural Observation System (C-BOS). The behavior system focuses on topographical aspects of objective behavior which can be observed during CBT to enhance consistency of coding among the two countries. In addition, we prepared independent evaluators for each country to confirm its interrater reliability.
The results of this study suggested that Japanese children demonstrated less readiness during the first CBT session, and specifically were less likely to respond to therapist questions about their anxiety than Australian children. In terms of the proportion of child, parent, and therapist talking, Australian children and parents talked more than Japanese families during the CBT sessions. This finding aligns with cultural norms I mentioned before. Moreover, only Australian therapists tended to show decreases in the amount of talking during the last session, whereas Japanese therapists maintained a similar proportion of talking through the sessions. This finding might suggest that Japanese therapists may need to temper their initiative-taking over time so as not to monopolize discussion and better facilitate transfer of control.
To finish, would you like to add any other comments regarding this subject?
SI: The research on cultural adaptation of cognitive behavior therapies are scarce, especially there is no study focusing on actual interactions during CBT sessions. The study which I mentioned lastly could provide practical suggestions that may be useful in the context of culturally adapted CBT programs delivered in both Eastern and Western countries. We need to accumulate more studies to shed light on clinical implications on cultural adaptation all over the world.
Benish, S. G., Quintana, S., & Wampold, B. E. (2011). Culturally adapted psychotherapy and the legitimacy of myth: A direct-comparison meta-analysis. Journal of Counseling Psychology, 58, 279–289. http://dx.doi.org/10.1037/a0023626.
Chun, C, A., Enomoto, K., & Sue, S. (1996). Health care issues among Asian Americans: Implications od somatization. In P. M. Kato & T. Mann (Eds.), Handbook of diversity issues in health psychology (pp. 347-365). New York: Plenum Press.
Creswell, C., Nauta, H. M., Hudson, L. J., March, S., Reardon, T., Arendt, K., ... Kendall. C. P. (2020). Research Review: Recommendations for reporting on treatment trials for child and adolescent anxiety disorders - an international consensus statement. Journal of Child Psychology and Psychiatry. https://doi.org/10.1111/jcpp.13283.
Essau, C. A., Ishikawa, S. Sasagawa, S., Otsui, K., Sato, H., Okajima, I., Georgiou, G. A., O'Callaghan, J., & Bray, D. (2013). Psychopathological symptoms in two generations of the same family: A cross-cultural comparison. Social Psychiatry and Psychiatric Epidemiology, 48, 2017-2026.
Forehand, R., & Kotchick, B. A. (1996). Cultural diversity: A wake-up call for parent training. Behavior Therapy, 27, 187-206.
Griner, D., & Smith, T. B. (2006). Culturally adapted mental health interventions: A meta analytic review. Psychotherapy: Theory, Research, Practice, Training, 43, 531–548. http://dx.doi.org/10.1037/0033-322.214.171.1241
Hall, G. C. N., Ibaraki, A. Y., Huang, E. R., Marti, C. N., & Stice, E. (2016). A meta-analysis of cultural adaptation of psychological interventions. Behavior Therapy, 47, 993-1014. https://doi.org/10.1016/j.beth.2016.09.005
Higa-McMillan, C. K., Francis, S. E., Rith-Najarian, L., & Chorpita, B. F. (2016). Evidence base update: 50 years of research on treatment for child and adolescent anxiety. Journal of Clinical Child and Adolescent Psychology, 45, 91-11.
Hwang, W. C. (2016). Culturally adapting psychotherapy for Asian heritage populations: An evidence-based approach. Cambridge, MA: Elsevier Academic Press.
Ishikawa, S., Kikuta, K., Sakai, M., Mitamura, T., Motomura, N., & Hudson, J. L. (2019). A randomized controlled trial of a bidirectional cultural adaptation of cognitive behavior therapy for children and adolescents with anxiety disorders. Behavior research and Therapy, 120, 103432. https://doi.org/10.1016/j.brat.2019.103432.
Iwamasa, G. Y., & Hays, P. A. (2019). Culturally responsive cognitive behavior therapy: Practice and supervision (2nd ed.). Washington D.C.: American Psychological Association.
Kendall, P. C. (1994). Treating anxiety disorders in children: Results of randomized clinical trial. Journal of Consulting and Clinical Psychology, 62, 100-110.
Saha, S., Beach, M. C., & Cooper, L. A. (2008). Patient centeredness, cultural competence, and health care quality. Journal of the Natural Medical Association, 100, 1275-1285.
Smith, T. B., Rodriguez, M. D., & Bernal, G. (2011). Culture. Journal of Clinical Psychology, 67, 166–175. http://dx.doi.org/10.1002/jclp.20757
Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53, 440-448.
Sundell, K., Beelmann, A., Hasson, H., & Schwarz, U. T. (2016). Novel programs, international adoptions, or contextual adaptations? Meta-analytical results from German and Swedish intervention research. Journal of Clinical Child and Adolescent Psychology, 45, 784-796.
Tanaka-Matsumi, J. (2011). Culture and psychotherapy: Searching for empirically supported relationship. In K. D. Keith (Ed.), Cross-cultural psychology: Contemporary theme and perspective (pp. 274-292). West Sussex, UK: Wiley-Blackwell.