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
26
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)
33
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
37
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
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