Running head: The Application of Cognitive Behavior Therapy on Asian Americans

The Application of Cognitive Behavior Therapy on Asian Americans

Gregory Cordes
General Psychology
PSY7540 Multi-Cultural Perspectives in Human Behavior
Spring 2008
jgcordes@comcast.net

Abstract
In this paper, I will identify some of the distinctive qualities of
Asian American culture, describe and explain the theoretical underpinnings and
application of cognitive behavioral therapy as well as its range of uses, and then
integrate the culture into the therapy and show the current research on that
application.

The Application of Cognitive Behavior Therapy on Asian Americans

Introduction
Asian Americans
Asian Americans distinguish themselves as culturally different from the mainstream
because they hold a collectivist orientation (Sue & Sue, 2003). Asians put
emphasis on family, individual needs come second. Asian families expect children
to be obedient, not to dishonor the family, and strive to achieve the goals of the
family. Chinese-Americans instill the importance of calmness and politeness in
their children. Families of Adolescent Asian Americans expect them to respect,
support, and assist their families even in the face of Western adolescent
independence, and autonomy. The parenting style of Asian Americans tends to be
different than mainstream America (Sue & Sue, 2003).
The structure of Asian American families is patriarchly and hierarchically, older
individuals in males occupy higher status (Sue & Sue, 2003). Asian Americans
expect their children to defer to adults, while communication flows from parent to
child. Asian American parents rely on directive and authoritarian parenting styles
in contrast to Euro Americans. Asian Americans believe lack of discipline to be
the source in behavioral problems of children. There are some differences in
parenting style within the Asian American community. The most egalitarian
relationships tend to occur in Filipino and Japanese American families. In
contrast, Chinese and Korean American parents take a more authoritarian approach -
and there are some differences in terms of emotionality between Asian Americans
and Euro Americans (Sue & Sue, 2003).
Asian Americans discourage strong public emotional displays that they
consider an indication of loss of control or immaturity (Sue & Sue, 2003). Even
within the family, emotional displays are discouraged. This holds true especially
for older children. Parents may use guilt and shame to train and control their
children. Family members show concern and care by serving the needs of their
relatives. Fathers are authoritative, suppressed emotional demonstrations, and are
not directly involved in child rearing. He is the “breadwinner”. Because fathers
are not directly involved in child-rearing, mothers play an intermediary role in
communication between father and children. Asian Americans expect mothers to care
for the emotional needs of the children. Mothers are less nurturing but more
responsive to their children than Euro American mothers, and use more physical and
verbal punishments. Academics play an important role in Asian American culture
(Sue & Sue, 2003).
Asian Americans believe the product of good upbringing is a successful career
achieve through academic performance of their children (Sue & Sue, 2003). For this
reason, Asian American children perform better academically than Euro Americans
(Sue & Sue, 2003). For example, Asian Americans perform better on mathematics
tests than both Euro Americans and African-Americans according to the Bell Curve
(Herrnstein & Murray, 1996). While the book remains controversial, given the
emphasis on academics and the universal nature of mathematics this seems a likely
conclusion - after all, in any culture 1 + 1 = 2. Asian American children devote
twice the time Euro American children on academics (Sue & Sue, 2003). As a result
of this emphasis on academics, many Asian American children fear academic failure.
In addition, Asian American adolescence or at greater risk of feeling depressed,
anxious, lack of praise, and isolated. In many cases, Asian-American parents
picked a career goal for their children typically in the hard sciences or in the
technical fields. Deviating from these career choices or academic failure can be a
source of conflict between family members. Asian Americans in contrast to Euro
Americans consider body and mind inseparable (Sue & Sue, 2003).
When experiencing emotional or psychological stress, Asian Americans frequently
complain about physical conditions (Sue & Sue, 2003). They see a connection
between physical illness and psychological pain. This can occur even with
psychotic patients. Asian Americans also suffer from the products of
discrimination and racism (Sue & Sue, 2003).
Asian Americans report higher rates of workplace discrimination as opposed to
Caucasians (Sue & Sue, 2003). For Southeast Asian refugees, this translates into
high incidence of depression (Sue & Sue, 2003). In addition, Asian Americans are
often stereotyped. Two of the most common are all Asian Americans are pretty much
the same, and all Asian Americans are foreign-born. In fact, half are born in the
United States (Anonymous, 2005). One of the reasons for this stereotyping is Euro
Americans cannot physically identify different Asian Americans, but an Asian
American is able to do this (Bascara, C., personal communication, 2005). In
addition to stereotyping, Asian American families may suffer parent and child
acculturation conflicts (Sue & Sue, 2003).
Asian-American parents want their children to maintain their Asian traditions,
attitudes, and values (Sue & Sue, 2003). On the other hand, in an effort to fit
in, many Asian American children want to discard those values, attitudes, and
traditions in favor of Western standards. These acculturation differences can
result in conflict, miscommunication, and misunderstandings. Identity issues
present another hurdle in the Asian American experience (Sue & Sue, 2003).
Asian American children straddle 2 cultures - on one hand conform to the demands
of traditional Asian standards while accommodating Western culture. As a result,
Asian American college women report lower self-esteem as well as less satisfaction
with their racial definition (Sue & Sue, 2003). Asian American identity can
follow one of four paths. They can assimilate, chooses Western culture over their
Asian culture. In Asian American Cancer separate, only identify with their Asian
culture. They can engage in integration or biculturalism, that is, maintained
their Asian values, but learns the skills of the dominant culture. Lastly,
marginalization may occur, reject their own culture but failed to adapt to the
mainstream (Sue & Sue, 2003). Refugees have special considerations.
Since 1975 approximately 1.5 million refugees have arrived from Southeast Asia
(Sue & Sue, 2003). The Khmer, Laotian, Cambodian, and Vietnamese make up the
majority. Typically, these immigrants do not have time to prepare for the move and
consequently are under more stress than other immigrants. Many must wait and
refugee camps in France, Austria, and the United States. Starvation of an
immediate family member is common among Cambodians, Vietnamese experience conflict
with the Viet Cong as a result of their association with the Central Intelligence
Agency. 86% of the Hmong wish to return to Laos, 75% experience unemployment, and
92% show stress related disorders. Refugees report family breakup, lack of
community ties, experience homesickness, worry about the future, have difficulty
with English, suffer unemployment, face culture shock, are unemployed, and have
high levels of depression and post-traumatic stress disorder. In addition, Asians
in general do not understand concept of psychotherapy and regard discussing family
problems as a source of shame. Asian Americans look for strategies the solution
based, and produce concrete results (Sue & Sue, 2003).
Cognitive Behavioral Therapy (CBT)
To achieve concrete results when serving Asian Americans Sue and Sue (2003) and
Tracey (2006) recommend CBT. CBT grew out of the work of Aaron Beck and Albert
Ellis, psychologist typically use it in conjunction with Rational Emotive
Behavioral Therapy (REBT) (The Jove Institute, 2007). REBT works according to an
ABC model - individuals experience an Activating event (A), reference the event to
a Belief schema (B), and respond with a Consequence (C). The center piece of CBT
is the Belief schema - it may be anxious, humorous, driven, rational or
irrational. The schema is not necessarily bad, but maladaptive or irrational
beliefs schema pose a threat to psychological health. For example, John is
invited to a party - someone says something bad about John (A), John believes
nobody likes him (B), and does not attend the party (C). C then takes another
unhealthy turn, “I am all alone, therefore no one likes me”, thus reinforcing the
irrational schema. The most difficult part of CBT is identifying the Belief
schema, determining if it is unhealthy, and implementing a rational alternative to
the client (The Jove Institute, 2007). Because CBT operates on such a basic
level, it is applicable to many psychological disorders. However, there are
certain central tendencies inherent in all CBTs.
CBT is not a distinct therapeutic device, there are several approaches including
Dialectic Behavioral Therapy, Rational Living Therapy, Cognitive Therapy, and
Rational Emotive Behavioral Therapy (National Association of Cognitive Behavioral
Therapist, 2007). Psychologists base CBT on a cognitive model on the emotional
response of the client. That is to say, the thoughts of the client cause their
feelings and as a result their behaviors, not situations, events, or people. The
client benefits when we can change the way they think and as a result they feel
better. CBT is time limit and therefore faster than traditional psychotherapy.
Typically, the average number of treatments is about 16. Psychoanalysis, on the
other hand, may take years. Clients know at the very beginning of therapy how long
it will last. CBT is instructive in nature and uses homework assignments to
reinforce the therapy. The client and the therapist decide when to end formal
therapy. Most therapies depend on a good relationship between the therapist and
the client - CBT focuses on teaching the client rational self counseling
techniques. CBT is goal oriented - the therapist and the client look for the
client's goals, and the therapist teaches and encourages achievement of those
goals while the client expresses their concerns, learn, and implement the
learning. Many forms of CBT rely on stoic philosophy, however - Cognitive Therapy,
Rational Living Therapy, Behavioral Therapy, And Rational Emotive Behavioral
Therapy do not. Stoicism emphasizes the importance of staying calm in an
uncomfortable situation (NACBT, 2007). I use this myself, however - it sometimes
unnerves of others, usually the ones that are not calm. CBT suggests in an
uncomfortable situations we have to problems, our reaction to the problem, and the
problem itself (NACBT 2007). CBT posits that we accept the problem and once we do
will we automatically feel better and are able to use our intelligence, energy,
knowledge, and resources to deal with the problem. Psychologists use the Socratic
Method in CBT. CBT therapists need a good understanding of their client's issues.
They encourage clients to question themselves. CBT is directive and structured.
Cognitive behavioral therapist maintain an agenda for individual sessions,
specific techniques and concepts, target what the client wants to achieve, allow
clients to select the goal, educate clients on how to achieve those goals, and
show clients how to do something not what to do. Psychologists base CBT on an
educational model. CBT make the assumption we learn behavioral and emotional
reactions. CBT gears therapy to unlearn undesirable reactions and learn better
ways of reacting. There is an additional gain with the educational aspect of CBT,
when we understand how and why people can continue to do well even after therapy
ended. CBT uses an inductive method. Many times things are not as they appear,
therefore CBT Theory focuses on rational thinking, and fact based thinking. CBT
therapists encourage clients to consider whether their assessment of a situation,
determine if their assessment is rational, and if not, discourage them from
wasting time about it. Home work is the centerpiece of CBT. CBT therapists assign
homework, typically in the form of reading assignments in an effort to reinforce
what the client has learned during therapy sessions (NABT, 2007). As I stated
earlier, because of the basic nature of CBT, it lends itself to the treatment of a
wide range of psychological disorders.
For example, therapists use CBT in the treatment of chronically parasuicidal
borderline patients with some success as compared to a “treatment as usual” group,
there were decreases in measures of hopelessness, depression, reasons for living,
and suicidal thoughts. The period of treatment was one year (Linehan et al. 1991).
CBT has proved effective in the treatment of chronic fatigue syndrome as compared
with a relaxation control group (Deale et al., 1997). 70% of the CBT group, 53
patients, achieved good results after 13 sessions and the results continue for at
least 6 months (Deale et al., 1997). CBT is effective in treatment of acute
stress disorder in an effort to prevent Post-Traumatic Stress Disorder (PTSD) even
after six months after treatment - fewer patients met the PTSD criteria (Bryant et
al., 1999). In another study, CBT shows effective in the treatment of a
generalized anxiety disorder as compared to Behavioral Therapy - CBT subjects show
lower measures of anxiety and depression, and higher measures of cognition (Butler
et al., 1991). We use CBT in the reduction of anxiety in school children (Morris
& Kratochwill, 1987). CBT is effective in the treatment of tinnitus, however –
benefits were short lived and nonexistent after a six months follow-up (Davies et
al., 1995). In 19 sessions over 18 weeks, CBT is as effective as interpersonal
psychotherapy for bulimia nervosa, with a 48% success rate after six months
(Fairburn et al. 1993). We have found CBT to be ineffective treatments for
cocaine addiction for a variety of reasons including its short-term application as
compared with other approaches, clinical trials that have shown it to be
effective, it is goal oriented and a structured approach, flexibility, and its
compatibility with other treatments (National Institute on Drug Abuse, 2005). For
example, we can use Naltrexone in conjunction with CBT in treating alcoholism with
some success (Anton et al., 2003). In a meta-analysis of 28 studies, we find that
CBT is an effective treatment for depression, more effective than pharmacological
therapy (Dobson, 1989; DeRubeis, 1999), behavioral therapy (Dobson, 1989), no
treatment control, and other psychotherapies (Dobson, 1989). Interestingly, “Like
other antidepressant treatments, CBT seems to affect clinical recovery by
modulating the functioning of specific sites in the limbic and cortical regions.
Unique directional changes in frontal cortex, cingulate, and hippocampus with CBT”
in Positron Emission Tomography studies of CBT on depression (Goldapple et al.,
2004).
Discussion
Cognitive Behavioral Therapy and Asian Americans
Sue and Sue (2003) recommend using CBT with Chinese clients. Lin (2001)
echoes this recommendation because he believes CBT is highly compatible with
Chinese values, worldviews, cultural characteristics, and beliefs. He reports CBT
we use extensively in the Chinese and Chinese American communities. For example,
53% of Taiwan therapists use CBT. One study showed a 62% rate of improvement for
Chinese clients with psychotic and neurotic disorders, 79% to 87% with neurotic
disorders and 82% with psychotic (Lin, 2001). Part of the attraction of to Asian
Americans, is its directive, structured, goal oriented, and the time based
qualities.
In 2008, Sarah Horrell did a meta-analysis of culturally specific CBT
studies. There were only 12, 4 of which conducted with Asian Americans. The first
study examines the effectiveness of CBT on depression in elderly Chinese
Americans. Researchers recruit participants from a church and an apartment
complex, they assign church members to the treatment group, and they randomly
assign the apartment complex participants to either the treatment or control
groups. The participants viewed a 25 minute videotape on CBT depression
intervention. Participants showed significant improvements in depression and
anxiety measures in the CBT group. The author points out the failure to randomly
assign the church members may have contaminated the study. In another study,
researchers randomly assign female Cambodian refugees to either a medication only
or medication and CBT groups for treatment of PTSD. Here to, the author suggests
the combination of treatments worked better. In the third study, Vietnamese
refugees clinically diagnosed with symptoms of PTSD or randomized in either a CBT
group or a wait list control group. Statistical analysis between groups showed the
CBT significantly reduced PTSD symptoms. In another study, Cambodian refugees
diagnosed with a combination of PTSD and Generalized Anxiety Disorder (GAD) or
random Lee assigned to a CBT or wait list control groups. After completion of the
CBT all the members of the control group still and symptoms of PTSD or GAD, 60% of
the treatment group did not (Horrell, 2008).
Conclusion
Clearly, from a critical thinking point of view the qualities of directive,
structured, goal oriented, and the time based problem solver on a broad range of
psychological disorders make CBT a good fit for Asian Americans. Lin (2001) does
warn even as a good fit some modifications to the therapy may need to be
addressed. While the experimental literature doesn't amount to very much, it does
look promising.

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