This chapter discusses how CBT and CBGT in particular have emerged as strong candidates for meeting some of the mental health needs of non-English-speaking immigrants and members of minority ethnic groups. Depression is the most common mental health problem of North American immigrants and minority ethnic groups, especially among women. We will explore how standard CBGT protocols for depression can be made appropriate and effective for different cultures. The practical, here and now focus of CBT helps immigrants cope with barriers to successful integration. The group process supports members in realizing their struggles are shared by other immigrants. Cultural adaptations include an explicit and expanded CBT focus on family and interpersonal issues. This chapter shows how CBGT for depression has been adapted to Chinese and Spanish languages and cultures, as well as African American.

CBT clinicians working in multicultural cities are responding in thoughtful and creative ways to the challenge of balancing fidelity to CBT principles with cultural competence and sensitivity. The potential for offering CBT to a larger global arena is attractive to many CBT therapists, who are painfully aware of how psychotherapy has traditionally been a luxury for the more privileged and affluent members of society. Given that some governments, nongovernmental organizations, and humanitarian groups, such as Doctors Without Borders, recognize the serious problems of untreated depression and anxiety (including posttraumatic stress disorder [PTSD]) opportunities exist for disseminating CBGT to people with fewer personal resources, whether within Western countries or in developing countries.

In what follows, I first share a CBGT program I was part of developing for Chinese-speaking immigrants to Canada. The second example describes a CBGT program for Spanish-speaking immigrants to the United States. Although these two examples cover highly different populations, they illustrate similar considerations for clinicians interested in creating CBGT that is culturally appropriate and competent. The examples may inspire clinicians and serve as a template for other types of culturally adapted CBGT.

A Chinese Cognitive Behavioral Treatment Program for Chinese Immigrants

A substantial number of immigrants to North America (Canada and the United States) have Asian origins (6.4%; 22.4 million). There are 5.1 million Asian Canadians (14.5% of Canada’s total population; Census, 2011) and 17.3 million Asian Americans (5.8% of the total U.S. population; Pew Research Centre, 2012). With the projected increase in this population, there is a need to develop and evaluate culturally appropriate treatments for Asian North Americans. In our efforts to meet some of these needs by developing a Cantonese-language and a Mandarin-language CBGT program to treat depression in Chinese immigrants to North America, we identified a number of culture-related differences in how participants responded to this program compared to their English-language counterparts. Although a program evaluation for the Cantonese groups using a treatment-as-usual design (mainly management by family doctor) showed that the CBGT intervention was overall highly effective in reducing symptoms of depression, we noted a number of culture-related differences in how Cantonese- and Mandarin-speaking clients respond to this CBGT program (Shen, Alden, Söchting, & Tsang, 2006). Of particular importance are issues related to referral and assessment procedures, conversion of Chinese terms for dysphoric affect into English, and cognitive restructuring for challenging negative automatic thoughts and biases in thinking.

Chinese CBGT Program Rationale

The Chinese CBGT programs were developed in response to a community need, given that individuals of Chinese heritage were underrepresented in our local mental health outpatient clinics. While the total ethnic Chinese population of Canada is presently 1.48 million (4.2%; Census, 2011), the suburb for which these programs were designed has a 47% ethnic Chinese population. Yet, rarely do Chinese people present for outpatient mental health treatment. This is, in part, of course due to language and culture barriers. Consistent with these clinical facts, research indicates that, in general, Asians in North America tend to underutilize mainstream mental health services relative to their population size (Bui & Takeuchi, 1992; Fugita, 1990; Snowden & Cheung, 1990), although they have as many, and as serious, mental health problems as their European-heritage counterparts (Li & Browne, 2000; Sue & Morishima, 1982).

There are various explanations for why Chinese people are reluctant to seek mental health treatment. Some writers propose that Chinese cultural values inhibit participation in mental health programs, especially group therapy. Concerns about bringing shame upon the family by disclosing that “all is not well” are prevalent in Asian collectivistic cultures where loyalty to the family often overrides individuals’ well-beings (Lin & Cheung, 1999). Also, a cultural emphasis on emotional restraint and inhibition may not mesh with some types of Western psychotherapy, which generally involve discussion of personal topics, exploration of intrapsychic phenomena (dreams, fantasies, wishes), and a focus on the individual’s needs and wants (Leong & Lau, 2001). Chinese people are also influenced by the teachings of Confucius who warned that excessive emotions are dangerous and can create social disharmony (Wong, 2011). People of Asian heritage are therefore generally less willing to disclose their personal problems to a mental health professional, let alone speak to an entire group of strangers.

Another explanation for ethnic Chinese people’s reluctance to seek mental health treatment pertains to pragmatic factors involved in accessing appropriate services. Even for nonimmigrants, it can be a challenge to navigate entry into effective mental health care. For Chinese immigrants to North America, there are a number of additional barriers. These include a lack of awareness of available mental health services, language problems that interfere with communication with mental health professionals, and concerns about the credibility of the treatment provider, especially if this person is perceived as a “Western” therapist (Iwamasa, 1997; Leong & Lau, 2001; Shin, 2002). Research on the importance of matching client–therapist language and ethnicity underscores how Chinese clients engage better with therapy if it is delivered by an ethnic Chinese therapist speaking Cantonese or Mandarin (Lin, 1994; Okazaki, 2000; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Consequently, the development of culture- and language-specific programs appears essential to provide effective psychological services to Asian immigrant populations. The programs discussed in this chapter all involve client–therapist ethnic and language matching, that is, the CBGT leaders spoke Cantonese, Mandarin, or Spanish. For immigrants who speak English, there is evidence that ethnic matching may not be crucial so long as clients and therapists speak the same language.

Despite some literature pointing to the importance of client–therapist ethnic match, this is not necessarily associated with better treatment outcomes. Therapists’ personal characteristics, such as their cultural sensitivity and empathy, are also highly valued by Chinese immigrant clients, often more than ethnic status alone (see Karlsson, 2005, for a review). Clinicians working in multicultural settings offer insightful perspectives on a potential double standard if they apply the belief in ethnic matching to a reverse scenario, perhaps one of a graduate clinical psychology student from China. Would he not be considered capable of offering CBT for depression to people of European descent? I have supervised several psychiatry residents whose first degrees were from Mainland China or Hong Kong. Their Caucasian clients indicated feeling both understood and helped by the various CBT they received. A match in language is obviously important, but to say that only personal and intimate familiarity with a certain culture equips a therapist to treat clients from that culture could potentially lead to deprivation of opportunities to strengthen our social fabric and to an endorsement of exaggerated cultural stereotypes as opposed to an acceptance of commonalities among people in emotional distress. Fears of coming across as culturally insensitive may be unfounded—so long as the therapist offers genuine interest in and empathy for their clients, along with demonstrating cultural competence.

Clinicians involved with developing CBGT programs for Chinese people agree that many aspects of CBT appear to mesh well with Chinese cultural values. Several studies show CBT to be helpful for depressed Chinese people (Dai et al., 1999; Wong, 2007). And clinician researchers agree that CBT is highly compatible with Chinese culture. Chinese people have less tolerance for ambiguity and prefer a structured therapy that offers practical and immediate solutions to their problems (Leong, 1986). CBT does not require in-depth discussion or analysis of developmental experiences or intrapsychic conflicts and therefore may be better suited to cultures that value emotional restraint. Along those lines of clinical reasoning, we presented our Chinese CBGT programs to the community as a course on mood management and self-change, rather than therapy. A literal translation of the program title was A Course on Diligent Practice of New Thoughts.

The program runs for 10 weeks with 2-hour weekly group sessions. Each group of 8 to 10 members is led by one or two either Cantonese- or Mandarin-speaking group therapists. The therapists are bilingual and, depending on level of training, are supervised by non-Chinese-speaking senior CBT therapists. Even if direct supervision is not needed, we prefer that both the English- and Chinese-speaking CBT group therapists meet regularly for peer supervision. This allows for an opportunity to discuss general issues related to delivering CBT in groups but also for dealing with specific cultural issues. Similar to CBGT for depression for English-speaking clients, the Chinese CBGT consists of a combination of didactic presentations by the therapist regarding strategies for mood management, and group discussion focused on applying those strategies to clients’ lives. The protocol incorporates standard CBT interventions for depression, such as mood monitoring, behavioral activation, goal setting that includes strategies for increasing social contacts, and the identification and challenge of unhelpful thoughts and beliefs using Thought Records. Each session also includes homework assignment.

Referral Issues

One challenge facing programs for ethnic minorities is reaching clients to inform them about mental health services and how to enroll in them. Our program sends informational material to Chinese health-care professionals and makes presentations on Chinese radio shows. These kinds of community outreach initiatives are similar to other immigrant CBGT programs. Our primary referral source is Chinese family physicians and psychiatrists, and their willingness to refer patients to the program is essential to treatment delivery. The majority of clients in our program say they have difficulty negotiating the referral process. This seems due either to lack of assertiveness with their physicians, physician reluctance, or problems understanding how the health-care system bureaucracy works in North America. When the referral process itself is a barrier, it does not help to reduce the stigma many immigrants feel with accessing mental health services. Fortunately, many referring Chinese physicians are well aware of the co-occurrence of somatic symptoms along with other indications of depression. Understanding this co-occurrence of somatic symptoms may make it easier for physicians to make appropriate referrals. It also provides an opportunity to educate physicians less familiar with various cultural expressions of depression.

Approximately one-third of our clients self-initiate their referrals. Moreover, nearly all express eagerness to attend the program and seem highly motivated. They look forward to their group treatment and are happy to find a service in their own language. Dropout rates are within a reasonable range at around 18%. We thus do not have much evidence suggesting that Chinese clients feel ashamed or concerned about stigmatization when coming to an outpatient psychotherapy program. The extent to which the program is presented as an educational course versus a mental health program may help ethnic Chinese people feel more comfortable with seeking help. We suspect it is one of the reasons for the high suitability of CBT to this cultural adaptation.

Assessment

While our Chinese clients have sufficient literacy to fill out the forms and questionnaires in Cantonese or Mandarin, some are less accustomed to filling out such documents than their North American counterparts. Considering how North American public health services tend to include numerous documents advising clients of the rights to confidentiality, how their personal data will be protected, limits to that protection, etc., clinicians working with clients not accustomed to this process may want to think about ways to reduce this barrier. Indeed, in Hong Kong, many people solicit the help of professional “form fillers” when handling formal documents.

Similar to English-speaking clients in a general mental health CBGT service, Chinese-speaking clients also attend an hour-long structured clinical assessment interview in their own language. Again, similar to English-speaking clients, they welcome the interview and are generally at ease during it. Many report that they feel better even after the assessment interview, stressing how they treasure the opportunity to speak with a mental health professional in their own language. Some of the findings gathered from the structured interview nevertheless have important implications for our understanding of culturally competent mental health services.

When asked about their mood, most clients report a dysphoric, or sad, affect. But a substantial majority denies being depressed. The term depressed is an uncommon word in the lexicon of everyday conversation in Chinese. It was translated into you-yu in Mandarin and yau-wat in Cantonese, probably during the days when Western psychiatry was introduced into China. You-yu and yau-wat both imply a somewhat different emotional construct than the English term depression. The problem with the word depression is not unique to the Chinese culture, but to many other non-Western cultures as well. Instead, sadness seems to be a concept common to many cultures (Brandt & Boucher, 1986). Our Chinese clients prefer words such as “sad” and “unhappy” instead of “depressed” when talking about their feeling states. In structured clinical interviews, Chinese clients endorse fewer symptoms of depression when asked directly and often fail to meet formal criteria for a mood disorder. This contrasts with how they talk about their problems. Their descriptions of day-to-day functioning suggest they do have significant problems with depression and especially with using helpful coping skills.

In Cantonese, the phrase denoting sadness is ng hoi sum, literally meaning “the heart is not open.” In Chinese culture, the heart is considered the seat of the psyche and the master of all emotions. It is therefore not surprising that psychology is translated as “the study of the logic of the heart” (sum lei hok). Our depressed Chinese clients do make repeated reference to their heart as either open or closed. It is important to recognize this as a metaphor for feelings because expressions of this kind can be mistaken as somatic complaints.

Another difficulty in assessing symptoms of depression in Chinese people involves inquiring about bodily symptoms related to sexual functioning. In general, Chinese people find it hard to distinguish between sexual interest and sexual behavior. When asked about their sexual interest, the majority interpret the question to be about their sexual behavior. They will therefore have difficulty saying they have sexual feelings if they are not actually in a relationship involving sexual connections. For example, several women reported their spouse being away for months working in Asia and they felt the question irrelevant. In contrast, non-Chinese clients are more likely to say they have sexual interests or feelings even when not having opportunities to engage in sexual behaviors with a partner. Or they will express difficulty with sexual arousal, as is common in depression, even if engaging in regular sexual activities with a partner. Questions tapping into sexual interest, which are common in many self-report questionnaires on depression, may not be useful when applied to Chinese clients. Further probing into this area during an interview could be considered too intrusive and voyeuristic according to Chinese standards.

Other difficulties in assessing depression revolve around the concepts of helplessness and hopelessness. The distinction between the two has been accorded clinical significance in the Western literature, especially when considering the risk for suicide. Unlike English-speaking clients, our Chinese clients have difficulty responding to questions about hopelessness. While they find helplessness (mo jor) easy to understand, many fail to see how hopelessness (mo mong) is any different from helplessness. It appears to them that both terms connote little control over their current and future problems. While many depressed Chinese clients volunteer feelings of helplessness, few talk about hopelessness. Some even look bewildered when asked about it. It is unclear whether this may relate to most Chinese subscribing to spiritual beliefs about not interfering with fate. Although the Beck Hopelessness Scale has been successfully translated into the Chinese Hopelessness Scale (Shek, 1993), this does not necessarily mean that hopelessness is a concept that Chinese clients are used to working with in daily living.

CBGT Treatment Issues for Depressed Chinese People

The vast majority of Chinese clients enrolling in CBGT for depression easily understand the treatment rationale for CBT. They are motivated to learn and apply the various presented interventions. There are, however, some unique challenges in applying CBT to this population—and some valuable insights and suggestions for protocol revisions continue to emerge.