Cognitive Behavioural Therapy

The available studies indicate that refugee and migrant youth will likely benefit from CBT in the same ways as non-migrant youth (Benish et al., 2011; Cardemil, 2010; La Roche & Christopher, 2009; Kazdin, 2008). Demographic characteristics such as age, gender, ethnicity, and symptom severity do not impact CBT’s effectiveness (Huey & Polo, 2008; Huey et al., 2014; Kendall et al., 2008; Walkup et al., 2008). The past 20 years has produced studies that support the use of CBT to treat youth who present to treatment for anxiety (Kendall et al., 2008; Franklin et al., 2011), and depression (March & Vitiello, 2009), posttraumatic stress disorder (Cohen et al., 2009), disruptive behaviour (Lochman et al., 2011), and challenges associated with autism spectrum disorder (White et al., 2013), substance use disorders (Waldron & turner, 2008), and eating disorders (Keel & Haedt, 2008). CBT is an effective treatment model appropriate for youth for a wide range of presenting problems and cultural identities (Friedberg et al., 2016).

A number of studies have examined whether culturally adapted forms of cognitive behavioural therapy (CBT) are more effective than are non adapted forms of CBT, whether culturally adapted treatment demonstrates positive outcomes, or whether certain components of CBT are more helpful than others (Jackson et al. 2006, Shen et al. 2006). These studies are important because CBT is effective for many different problems (eg, anxiety and depression) and for different ethnic populations. For example, Hinton et al. (2005) used CBT to treat Cambodian refugees by using culturally appropriate visualisation tasks. Furthermore, because CBT is often delivered with a fixed format or manualised script, it can readily incorporate cultural adaptations and be tested. Findings from the CBT studies provide consistent indications that cultural competency interventions are effective, and two of the studies (Kohn et al. 2002, Miranda et al. 2003) found that cultural competency adaptations to CBT were superior to nonadapted CBT (Stanley et al, 2009).

This section defines and illustrates content and process factors that comprise competent CBT for refugee and migrant youth. Case scenarios from the work of Friedberg et al. (2016) demonstrate the ways that CBT can be modified to address the cultural factors salient to practice with migrant and refugee youth.

Target Monitoring

Target monitoring is the data collection phase of CBT treatment and serves to both increase awareness and establish a baseline of symptoms. Clients and/or parents are asked to track thoughts, feelings, behaviours, and physiological sensations—essentially, clients gather information relevant to their presenting problem (Friedberg & Gorman, 2007). Thought records are one example of a method for monitoring automatic thoughts, situations that elicit particular beliefs, and patterns of cognitive distortions (Friedberg & Gorman, 2007). Target-monitoring techniques can and should be adapted to the patient’s age, cultural background, interests, etc. (Friedberg et al., 2016). For example, young children respond well to filling in faces with expressions or colouring in a thermometer to reflect the intensity of their emotions; adolescents may simply report intensity on a scale from 0 to 10.

Cultural adaptations can easily be integrated into the target monitoring phase as well. For example, a young Chinese client may experience her anxiety primarily as somatic symptoms such as stomach ache, numbness, tingling, and a racing heart. As a result, monitoring somatic symptoms and physiological arousal using culture-specific language (eg blockages of Xi) rather than asking her to rate her anxiety will make this activity more relevant.

Clinicians can also utilise self-report measures such as the Children’s Depression Inventory CDI -2 (Kovacs, 1992) and Screen for Child Anxiety Related Emotional Disorders (SCARED) (Birmaher et al., 1997). The CDI-2 is available in English and Spanish, and the SCARED is available in Arabic, Chinese, English, French, German, Italian, Portuguese, and Spanish. These measures allow young clients and families to monitor symptoms over time using an objective assessment.

Target monitoring also facilitates functional analysis of problem behaviours by identifying antecedents and consequences. Furthermore, monitoring emotional intensity in response to feared situations enables clients and clinicians to collaboratively develop a hierarchy of feared stimuli for graduated exposure. Target monitoring provides essential data that guides later phases of treatment (Friedberg et al., 2016).

Cultural adaptations to CBT produce lower attrition rates and greater patient involvement in treatment among ethnic minority patients. Thus, if the particular cultural alteration (eg, including extended family in sessions or predominantly targeting physiological symptoms rather than including cognitive) keeps more children in treatment and offers equivalent effectiveness, the change represents a good standard of care (Cardemil, 2010). However, cultural adaptation must preserve the core treatment ingredients of CBT while allowing for flexible integration of diverse perspectives and values (Friedberg, et al., 2016).