Dolores Subia BigFoot, PhD

Susan R. Schmidt, PhDOUHSC Center on Child Abuse and Neglect,

Oklahoma City, OK

Incorporating Family Culture and Spirituality into the TF-CBT Healing Process

DS BigFoot, 20082

Indian Country Child Trauma Center(ICCTC)

The mission of the ICCTC is to improve treatment and services for Native children and

adolescents in Indian Country who have experienced traumatic events

PROJECT MAKING MEDICINE -Training in Treatment of

Child Physical and Sexual Abuse

www.icctc.org

What is Culture?

Cultural identity describes an individual’s affiliation or identification with a particular group or groups.

Cultural identity arises through the interaction of individuals and culture(s) over the life cycle. Cultural identities are not static; they develop and change across stages of the life cycle.

Religion and Spirituality

Religion is organized, with each religion having its own set of beliefs and practices designed to organize and further its members’ spirituality.

Spirituality, on the other hand, is typically conceived of as a personal matter involving an individual’s search for meaning; it does not require an affiliation with any religious group (Cook, 2004).

Cultural Influences

(Hays, 2013)

Age & GenerationalInfluences Develop-

mental Disabilities

& Other Disabilities

Religion & Spirituality

Ethnic & Racial

Identity

Socio-economic

Status

Other Influences

Sexual Orien-tation

Indigenous Heritage

National Origin

Gender

American Indian/Alaska Native Affiliation ModelCultural Practices, Values, and Lifestyle (BigFoot, 2009)

High/Strong Affiliation

Identity as AI/AN is secure

Highly desirous to maintain high/strong

affiliation

May have other cultural heritage(s) that

are not assumed

Limited or No Affiliation

Identity as AI/AN is insecure

Highly desirous to acquire high/strong

affiliation

May have other cultural heritage(s) that are

not assumed or are not valued

Affiliation marginal

Limited or No Affiliation

Identity as non-AI/AN is secure

Limited or no interest in affiliation with AI/AN

or other cultural base

May or may not be expressive about limited

interest in own AI/AN background/heritage

May identify to some degree with other

cultural heritage(s)

Has found value in other aspects of

self-identity

High/Strong Affiliation

Identity as non-AI/AN is secure

Has a high/strong affiliation with selected or

elected heritage(s)

Highly values maintaining high/strong

affiliations with selected or elected

heritage(s)

Culture and Trauma

How do you conceptualize the relationship between Culture and Trauma?

Our lives are

shaped by

traumas faced

by past

and present

generations.

Intergenerational Trauma – The transfer of

emotional and psychological impacts from

a first generation trauma survivor across

generations via complex posttraumatic

stress disorder mechanisms

Historical trauma – A constellation of

characteristics associated with massive

cumulative group trauma across

generations. Historical trauma differs from

other forms of trauma in that the traumatic

event is shared by a collective group of

people who experience the consequences

of the event.

What is your family’s intergenerational trauma story and

in what ways has it shaped you and your generation?

Immigration

Slavery

Natural

Disaster

Suicide Accident

Abuse

Sexual

Assault

Death of

Loved One

MiscarriageCombat

ExposureViolence

Exposure

War ExposureTraumatic

Grief

Forced

Displacement

Poverty

Cultural Violence

Racism

Terminal

IllnessSystem Induced

Trauma

Terrorism

Crime Victim

Assigning of Family Names

Cultural Traditions/Practices

Family Location Family Values/Beliefs

Health-Related Behaviors

Immediate or Extended Family

Connectivity

Family Interests/Hobbies

Family Financial &

Educational Levels

Spiritual or Religious

Beliefs/Practices

Family Size

Mental Ilness

ep·i·ge·net·ics

the study of changes in organisms

caused by modification of gene

expression rather than alteration of the

genetic code itself.

Holocaust Survivors and

Historical Trauma

Individual

Historical Trauma Responses(Historical Trauma and Unresolved Grief: Implications for Indigenous Healing and Research)

Maria Yellow Horse Brave Heart, PhD

Posttraumatic Distress

• Physical Complaints

• Fear

• Depression

• Anger

• Hypervigilance

• Dissociation

• Emotional Numbing

• Poor Emotion Regulation

• Low Self-Esteem

Self-Destructive Behavior

• Substance Use

• Self-Harm

• Risk Taking

• Suicidal Ideation

• Fixation on Trauma

• Survivor Guilt

• Victim Identity

• Compensatory Fantasies

Familial

Historical Trauma Impacts Intergenerational Impacts

Example Losses:

Cultural Language and Identity

Family Traditions and Stories

Spiritual Practices

Change in Cultural/Familial Values

Increased Culture of Dependency

Intragenerational Impacts

Example Impacts:

High Rates of Abuses

Family and Partner Violence

Child Abuse – Emotional, Physical, Sexual, Neglect

Loss of Family Relationships

Poor Social Conditions

Poor Health Conditions

Incarcerations

Accidental Deaths

Cultural Healing

from Trauma

Cultural Strengths and Supports to aid in Trauma Healing

Pride and participation in one’s culture Social skills, traditions, knowledge, and practical skills

specific to the client’s culture Bilingual or multilingual skills Traditional, religious, or spiritual practices, beliefs, and

faith Generational wisdom Extended families and nonblood kinships Ability to maintain cultural heritage and practices Perseverance in coping with racism and oppression Culturally specific ways of coping Community involvement and support

Source: Hays 2008

TF-CBT

Cultural Enhancements

Maintain fidelity to TF-CBT model structure PRACTICE Components

Collaborate with family to determine what level of cultural integration into TF-CBT best fits their needs.

Therapists are encouraged to learn about the customs, traditions, stories and symbols relevant to cultures within their geographic area.

Cultural Enhancement Considerations

BigFoot & Schmidt, 2009

Traditional TF-CBTCulturally –

Enhanced TF-CBT

High/Strong Dominant Culture Identity

Limited Minority Culture Identity & Limited Interest

Limited Minority Culture Identity & High Interest

High/Strong Minority Culture

Identity

Integrating Culturally-Based Enhancements into the TF-CBT Model

Incorporate Increasing Cultural Enhancements. Integration is an Intertwining of Cultural Practices and Beliefs.

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Honoring Children

Mending the Circle

Process of EBT Adaptation

Identification of traditional teachings and concepts

Parenting/nurturing/therapeutic practices

Ways of teaching and learning

Native cultural worldviews to explain behavior

Examples of meaningful Native concepts:

• Circle

• Respect

• Honor

• Wisdom

• Harmony

RELATIONAL

MENTALPHYSICAL

EMOTIONAL

SPIRITUAL

Honoring Children – Mending the Circle

Well-Being Model Framework

Storytelling

Offerings/gifts

Ceremonies

Vision seeking

Sweatlodge

MeditationDrumming

Listening/watching/doing

Talking Circle

Extended Family

Singing

HonoringSmudging

Dancing

Historical rides/walks

Naming Ceremonies

Society/clans/bands

Humor/teasing

Resiliency

Therapeutic Native Practices

Language

Questions for family:

•Which primary caregiver(s) will be available to regularly participate in sessions in order to provide continuity?

•Who else will be involved in treatment sessions? In what way? How can we most effectively integrate these individuals into treatment?

•Who will be involved in healing activities outside of treatment sessions? In what way?

Integrating “All My Relations” into Treatment

When animals get hurt, their natural instinct is to clean their wounds to promote healing. This is

their way of taking care of themselves.

The bear may find it painful to remove debris from an injury. But, the bear does this because he

knows that this is necessary for his body to become well. Healing must take place for the bear to

be able to use his body to gather food and to protect himself.

The bear must tend to the hurt until it is healed. Then he is ready to return to his path on the Circle.

Story to explain the importance of trauma treatment

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Example HC-MC Relaxation Enhancements

Ensure that images are appropriate and not a violation of tribal or cultural mores.

Image ideas:

Controlled Breathing - the sway of a shawl, trees swaying in the breeze, birds in flight

Muscle Relaxation – flexing and releasing a fishing rod, tensing and releasing a bow, in and out motion of paddling a canoe

Traditional Activities

Drumming, Playing Flute, Dancing

Beadwork/Quilting

Woodwork

Leatherwork

Herbs and Gardening

Tending Animals/Pets

Family/Extended Family Time

Soothing Sports

Canoeing Walking/Hiking

Swimming Horseback Riding

Active Sports

Team Sports Running/Jogging

Rodeo Rock Climbing

Spiritual Traditional Activities

Singing/Chanting

Requires deep breathing

Use of repetition

Meditation/Prayer

Helps with centering

Eliminates external stimulation

Smudging

Spirituality: Treatment Goals

Teach that wellness is spiritual, emotional, mental, physical, and relational balance and that these are all interconnected aspects of ourselves

Help the family to draw upon traditional healing practices to assist child and family in working toward spiritual balance

Help instill an enthusiasm for life, a sense of hope and joy, and a willingness to meet new challenges

Increase child’s self-identity/self-esteem and their tribal identity.

TF-CBT Components Activity

Client Cultural Affiliation

In TF-CBT Treatment

• Where were you born? • Whom do you consider family? • What was the first language you learned? • Which other language(s) do you speak? • What language or languages are spoken in your home? • What is your religion? How observant are you in practicing that

religion? • What activities do you enjoy when you are not working? • How do you identify yourself culturally? • What aspects of being ________ are most important to you? (Use

the same term for the identified culture as the client.) • How would you describe your home and neighborhood? • Whom do you usually turn to for help when facing a problem? • What are your goals for treatment?

Example Questions to Assist in Cultural Learning

Impact of trauma and other crisis events

• How has trauma affected your family across generations?

• How have traumas or other crises affected you and/or your family?

• Has there been a specific family crisis?

• Did the family experience traumatic events prior to migration—war,

other forms of violence, displacement including refugee camps, or

similar experiences?

Religious and cultural institutions, food, clothing, and holidays

• Are there specific religious holidays that your family observes? • What holidays do you celebrate? • Are there specific foods that are important to you? • Does clothing play a significant cultural or religious role for you? • Do you belong to a cultural or social club or organization?

Example Questions to Assist in Cultural Learning

1. What do you think caused [use individual’s words *]?

2. Why do you think it started when it did?

3. What do you think your [ * ] does to you?

4. What are the chief problems it has caused for you?

5. How severe is your [ * ]? What do you fear most about it?

6. What kind of treatment/help do you think you should receive?

7. Within your own culture, how would your [ * ] be treated?

8. How is your community helping you with your [ * ]?

9. What have you been doing so far for your [ * ]?

10.What are the most important results you hope to get from treatment?

Cultural Awareness Tool (CAT)Kleinman, Eisenberg and Good (1978)

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Example Challenges Related to Incorporating Client

Cultural Affiliation into Treatment

When the client has no strong cultural affiliation, but wants to learn more

When the youth and caregiver(s) differ in their cultural affiliations or their affiliation levels

When the therapist has limited knowledge about the client’s cultural group(s)

When the client’s trauma-related beliefs are culturally associated. Examples: “When I fight, I’m being a warrier.”

“My child is no longer pure/a virgin because she was raped.”

Others?

Therapist Cultural Affiliation

In TF-CBT Treatment

https://www.clchpa.org/assessment.php

Georgetown University National Center for Cultural Competence

Cultural and Linguistic Competence Health Practitioner Assessment

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Role of the Provider in Trauma Healing

Serve as guide on pathway toward healing

Impart a sense of confidence in the healing process and the methods utilized

Call upon other helpers and healers to assist child and family

Call upon the family’s wisdom to assist in their own child’s and family’s healing

Affirm the child and family’s sense of well-being and balance

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Example Challenges Related to Differences in Therapist and Client

Cultural Affiliation

Concern about being inadvertently culturally insensitive in words or actions

Concern that client may negatively view the client-therapist cultural difference

Uncertainty about how much of the client’s cultural affiliation(s) to bring into treatment

Others?

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Final Thoughts…

Therapist – Client difference is the norm rather than the exception.

Know thyself – Understand your own cultural affiliation.

Therapists are not expected to be cultural experts.

Create a safe and inviting therapeutic environment for conversations about culture and spirituality.

Learn from the individual and family.

Explore with the family the possible inclusion of other helpers and healers in the healing process.

These are our gifts for you to

use on your journey…

GenderAge &

Generational Influences

Religion & Spirituality

Ethnic & Racial Identity

Socio-economic

Status

Indigenous Heritage

Other Influences

Develop-mental

Disabilities & Other

Disabilities

National Origin

Sexual Orien-tation