Cross cultural applications of schema therapy DANIELA HO TAN, - - PDF document

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Cross cultural applications of schema therapy

DANIELA HO TAN, CLINICAL PSYCHOLOGIST B.PSYCH(HONS), M.PSYCH(CLIN)

INFO@MINDWEALTHPSYCHOLOGY.COM.AU

Culture in psychology

“Within the field of psychology, multicultural counseling can be described as a therapy process that applies treatment approaches and therapy goals that are consistent with the life experiences, contexts, and cultural values of clients from diverse backgrounds.” (Graham, Sorenson & Hayes‐Skelton, 2014)

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Cultural diversity in Australia

With a population of 23.4 million Australia is one of the most culturally and linguistically diverse populations in the world How many clinicians here work with clients of different ethnicities? How many clinicians factor a client’s ethnicity/culture into the clinical formulation?

Cultural diversity in Australia: The Census

Table from Australian Bureau of Statistics (2017)

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Generations of Australians

• Aged <40 were more likely to have

both parents born in an Asian country

• Aged >40 were more likely to have

both parents born in a European country

Differences between Asian and Western cultures

• Asian cultures tend to be more collectivistic – individuals have an interdependent view of

themselves

• Western cultures tend to be more individualistic – individuals tend to have an independent

view of themselves

Table from Vinall, Riddell & Greenberg (2011).

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Asian culture & psychology

• Culture affects support‐seeking behaviours (Markus and

Kitayama, 1991)

• East Asians and Asian Americans are less likely than European

Americans to talk about a stressful event

• East Asian individuals more likely to engage in implicit social

support

• People of Chinese background are less likely to seek

psychological help and are more likely to drop out of therapy (Guo & Hanley, 2015)

• Psychological issues in Asian cultures are associated with

shame and “weakness” (Williams, Foo, & Haarhoff, 2006)

• Asian populations more likely to report somatic distress than

psychological distress due to stigma (Grover & Ghosh, 2014)

Asian parent stereotypes

• Tiger or helicopter parenting (authoritative)
• Pressure on child to be “perfect” and “the best”
• Strong hierarchical structure and focus on family

coming first

• Great value placed on wealth, career and status
• Punitiveness and criticism used as a “motivating”

tool

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Case study: Jessica*

Jessica is a lady in her 20s who was referred by her GP for anxiety and depression. Her husband Joe (also in his 20s, Australian) was also concerned about her suicidal ideation. Background:

• Born in New Zealand to Filipino parents
• Jessica was the second oldest with one older sister and two younger brothers
• When she was 6 months old, her parents placed her and her older sister in the care of two

aunts in New Zealand (as her parents were on a temporary visa)

• Minimal contact with parents – only saw them three times by the age of 12
• Raised by her two aunts in a challenging, high pressured, and punitive household

Background cont.

• Jessica moved to Sydney at age six
• Changed schools four times, moved homes frequently
• Frequent feelings of loneliness, isolation and being “unwanted” as a child
• Sexually assaulted in a shopping centre in primary school resulting in a wariness of men and

PTSD symptoms

• Sexually harassed at work on three occasions by male staff
• Discriminated in the workplace due to her ethnicity
• First boyfriend was verbally and emotionally abusive – criticised her “dark skin”
• Parents moved to Sydney five years ago
• Ongoing family conflicts where she is always the “middle person”

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Presenting symptoms

• Frequent suicidal ideation and plans
• Thoughts of self harm and previous attempts with cutting
• Emotionally dysregulated – feelings of numbness/nothing or flooding of emotions
• Intrusive thoughts “felt like the devil” (was a reflection of her religious and cultural beliefs)
• Panic attacks
• Social withdrawal and avoidance

Pre‐YSQ scores

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Pre‐SMI scores Formulation Formulation

• Abandonment
• Social isolation
• Failure
• Vulnerability to harm
• Enmeshment
• Subjugation
• Self sacrificing
• Admiration seeking
• Unrelenting standards
• Vulnerable

child

• Angry child
• Impulsive child
• Punitive parent
• Demanding parent

Happy child Healthy adult Compliant surrender Detached protector Detached self soother

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The role of culture in Jessica’s treatment

• Addressing how culture helped shape some of the schemas and modes during the formulation
• Understanding what “Healthy Adult” looked like in a cross‐cultural context
• When dealing with her family Jessica engaged in detached protector and compliant surrender modes to

a degree (mindful awareness) to maintain the collectivistic harmony (functional coping) and as a way of showing “respect” to her parents/aunts

• In other settings (e.g. work, friends) Jessica asserted her emotional needs more easily as they were

more individualistic settings

• During imagery rescripting acknowledgement of Jessica’s cultural background helped to

balance her collectivistic view (respect to elders/family) and her individualistic view (“I should not have been treated like that”)

• Use of her Asian name

The role of culture in Jessica’s treatment

• Chair work with Jessica’s Demanding & Punitive Parent to understand cultural values
• Jessica related these two modes as being the internalisation of her family’s desires for her success on a

family level (honour vs shame)

• General discussion around the intersection of collectivist and individualist values for Jessica
• Learning to separate self from husband and sister (to be independent) and still feel a part of the

family/community to allow for a fusion of values

• Overall, Jessica responded well to schema therapy and her anxiety and depression symptoms
• improved. She is now better at recognising her emotional needs and knowing who to ask and

how to ask for them to be met.

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From pre‐tx to 10 session From pre‐tx to 10 session

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Working within a culturally sensitive framework

• Understanding the cultural origins of the client can help inform the understanding of the

schema development and the functions of their modes

• Definitions of Healthy Adult can vary within a cultural context and it is important to factor this

in when practising schema therapy

• Distress tolerance is important when the client’s change (to a stronger Healthy Adult) is perceived to be

“culturally inappropriate” by their peers/family

• Beliefs such as “I must take care of others before myself” or “If I say no then I am selfish” are

within Western cultural reference considered to place unrealistic demands on the individual. However, in an Asian context these are part of fundamental collectivistic values and can form the core of a client’s cultural identity. Challenging this prematurely can result in a rupture of the therapeutic relationship (Chen & Davenport, 2005; Shen et al., 2006).

Working within a culturally sensitive framework

• Understanding how culture affects the therapist‐client relationship
• E.g. Confucianism places great emphasis on social hierarchy (Wu et al., 2002) and within the therapy

relationship the client often expects the therapist to be more authoritative in giving instructions and directions (“tell me what to do”). This can be advantageous when initially doing work with limited reparenting as the therapist can be more directive at the start of therapy and mode healthy adult to the client

• Understanding how therapist cultural values and client cultural values may differ is important as what is

“normal” in one culture may not be in another culture

• Recognising how different cultures perceive emotions
• Disputing the view that having emotions is “weak” (destigmatising)
• Understanding why different cultures may have contrasting views of emotions (e.g. in war‐affected

countries) and how this can affect the schemas & modes

• Rushing into emotions can cause a client to disengage and drop out of therapy

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Questions to consider

• Is schema therapy suitable for this client? Is it the right

timing?

• Will cultural modifications still preserve the integrity of

schema therapy?

• Do I have a good understanding of my clients’ culture and

how it affects their schema (and mode) development?

• How does my own cultural value system affect my

delivery of schema therapy and the suggestions I make?

• How much change is realistic for the client without them

feeling they are compromising their cultural beliefs? ….all just the tip of the iceberg!

References

Australian Bureau of Statistics, 2017, 2016 Census: Multicultural, viewed 10 February 2019, http://www.abs.gov.au/ausstats/abs@.nsf/lookup/Media%20Release3 Chen, S. W. H., & Davenport, D. S. (2005). Cognitive‐behavioral therapy with Chinese American clients: Cautions and modifications. Psychotherapy: Theory, Research, Practice, Training, 42(1), 101‐110. Graham, J. R., Sorenson, S., & Hayes‐Skelton, S.A. (2013). Enhancing the cultural sensitivity of cognitive‐behavioral interventions for anxiety in diverse populations. Behavior Therapy, 26(5), 101‐108. Grover, S., & Ghosh, A. (2014). Somatic symptom and related disorders in Asians and Asian Americans. Asian Journal of Psychiatry, 7(1), 77‐79. Guo, F. & Hanley, T. (2015). Adapting cognitive behavioral therapy to meet the needs of Chinese clients: Opportunities and challenges: CBT and Chinese Culture. PsyCh Journal, 4, 55‐65. Markus, H.R., & Kitayama, S. (1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98(2), 224‐253. Shen, E. K., Alden, L. E., Söchting, I., & Tsang, P. (2006). Clinical observations of a Cantonese cognitive‐behavioural treatment programme for Chinese

• immigrants. Psychotherapy: Theory, Research, Practice, Training, 43(4), 518‐530.

Vinall, J., Riddell, R. P., & Greenberg, S. (2011). The influence of culture on maternal soothing behaviours and infant pain expression in the immunization context. Pain Research & Management, 16(4), 234‐238. Williams, M. W., Foo, K. H., & Haarhoff, B. A. (2006). Cultural considerations in using Cognitive Behaviour Therapy with Chinese People: A case study

• f an elderly Chinese woman with generalised anxiety disorder. New Zealand Journal of Psychology, 35(3), 153‐162.