Culture Free CBT for Diverse Groups

*Peter Phiri, Isabel Clarke, Lydia Baxter, Kathryn Elliot, Shanaya Rathod and Farooq Naeem*

## **Abstract**

Traumatic experiences are known to have a significant impact upon one's physical and mental health. Post-traumatic stress disorder (PTSD) is understood to be a common mental health consequence of trauma. However, Complex Trauma and consequences of adverse childhood experiences appear more prevalent and a serious public health concern that hinders the individual's daily existence, thus emphasising the need to implement a culturally free treatment intervention. In this chapter, we begin by introducing traumatic experiences in several contexts and explore the treatment for trauma. It will focus on a research study that employs Comprehend, Cope and Connect (CCC), a third wave CBT approach, to deliver a culturally free form of therapy that has been adapted for individuals from diverse populations. The CCC approach's relevance to cultural adaptation is explained and discussed through the use of two case examples from the main study. The Culture Free study found that CCC was both feasible and acceptable in diverse populations, echoing existing research on cultural adaptations which found use of mindfulness to be accepted and appreciated as an effective intervention that can elicit concrete positive change across a broad range of mental health presentations, including trauma and transdiagnostically. Further investigations utilising a robust methodology and powered sample are warranted in particular with diverse populations presenting with complex trauma.

**Keywords:** comprehend, cope, connect, CBT, trauma, ethnicity, culture

## **1. Introduction**

This chapter explores the treatment of trauma taken in a research study employing the Comprehend, Cope and Connect (CCC), third wave CBT approach, in delivering therapy to people from diverse ethnicities within a primary and secondary care service setting. CCC and its relevance to the treatment of diverse ethnicities will be explained; the CCC approach to trauma will be elucidated, and illustrated by discussing two case examples in detail from the main study.

Trans-diagnostic approaches have been gaining favour recently [1, 2]. Promising outcomes have been found in trials of therapy that is trans-diagnostic across anxiety disorders [3, 4]. The need for more expertise in treatment of trauma within psychotherapy services such as recognised by Murray [5] 's programme to teach trauma focused CBT to 20 therapists from 10 IAPT services resulting in improvement in client outcomes on a PTSD measure following the training.

Because the approach used is trans-diagnostic, and formulates linking current crisis with past adversity, a broader definition of trauma is used. The study offers the opportunity to review aspects of trauma and past adversity as these impinge on current mental health challenges in a broad community sample, not selected specifically for trauma. This data allows a sense of the continuum of impact of the past on the present within an ethnically diverse, general mental health, sample to be gained.

#### **1.1 Trauma in context**

Complex trauma refers to repeated and cumulative trauma that usually occurs over a period of time and within a specific context. The term was developed in the past decade by researchers who discovered that certain forms of trauma were more complicated than others [6, 7]. Many forms of trauma fall into the category of complex trauma including, domestic violence and attachment trauma, due to these forms of abuse occurring over a significantly extended period of time. The understanding extends to other types of traumatization occurring in childhood and/or adulthood for example, armed conflict and war, displacement, refugee status and forced relocation. Trauma may also result from chronic and ongoing health conditions due to a single event such as being witness to a sudden traumatic death of another. While the concept of complex trauma has been accepted, neither the DSM nor the ICD has included it; however, the upcoming ICD 11 is going to include the diagnosis of complex PTSD to describe complex trauma.

There is a vast body of research that demonstrates the strong association between adverse childhood experiences and trauma and the development of negative health and social outcomes later on in life [8]. Compelling research on the Adverse Childhood Experiences (ACEs) has aided in comprehending these links [9]. ACEs refer to any traumatic or commonly occurring stressful event, such as various forms of abuse, neglect and witnessing violence, which occurred before the age of 18 years old. Several large scale population based studies confirm the causal relationship of ACEs with poor emotional and physical outcomes. Bellis [10, 11] studies reported 50% of children within the UK experience at least one ACE, with four or more ACEs experienced by 12% of the UK population. Those individuals who experience a greater number of ACEs are at a higher risk of negative socioeconomic issues such as, lack of education and job opportunities, increased risk of experiencing intimate partner violence, low emotional wellbeing and life satisfaction. Furthermore, if a person experiences one form of abuse, there is an 87% increase they will endure other forms of abuse. This equates to the more abuse one experiences the higher their risk of negative health and psychosocial outcomes in years to come [9].

The various mental health outcomes for which ACEs are risk factors is very broad. Those that occur during childhood, include attention-deficit hyperactivity disorder and oppositional defiant disorder; and during adulthood include, depression, anxiety disorders and personality disorder as examples [12]. Individuals who have been subjected to childhood trauma of physical or sexual abuse are more prone to get an admission to a psychiatric hospital; increase of self-harm and suicidal behaviour, and an overall higher global symptom severity [13]. Kessler et al. [14] provided conclusive evidence from 21 countries, which stated childhood adversities associated with maladaptive family functioning (e.g., child abuse and parental mental illness) were the strongest predictors for mental health disorders. The implications of the research findings are significant in depicting the causal relationship of childhood adversity and mental health disorders in order to facilitate the development of appropriate treatment plans.
