[acb-hsp] Practice of CBT, Culturally Based

Sat Jul 30 12:53:45 EDT 2011

The Practice of Cognitive-behavior

Therapy in Roozbeh Hospital: Some

Cultural

 and Clinical Implications of Psychological Treatment in Iran

by Habibollah Ghassemzadeh

THE PROBLEM

Despite wide acknowledgment of the role of culture in human behavior

, the study of culture on the practice of psychotherapy in general, and

cognitive-behavior therapy

 (CBT) in particular, has been largely ignored in mainstream psychology. Up until

the 1980s, most psychotherapy practice, including CBT, was guided by assumptions

that the constructs and principles developed in the United States with European-Americans

applied to individuals everywhere (Vera, Vila, & Alegría, 2003, p. 521). There was

a belief that CBT was based on universal assumptions, sustaining the use of similar

methods, constructs, measures, and therapies across

cultural

 groups. Different voices from different sources, however, changed the picture. For

example, Sue and Zane (1987) claimed that traditional forms of treatment should be

modified for individual clients because these were geared primarily for mainstream

America. They believed diat treatment should match, or fit, me

cultural

 lifestyle or experiences of die client (p. 38). The relevance of culture, according

to their view, can be studied in three areas of psychotherapeutic intervention: 1)

problem conceptualization, 2) means for problem resolution, and 3) treatment goal.

Within social psychology, there has been a dramatic increase in the study of social

cognition - how individuals perceive and interpret their social world. One of subset

of social cognition that has become important in clinical psychology and psychopathology

is the concept and process of attribution, which grew from research on locus of control

(Rotter, 1966). The observed performance for attributions to internal dispositions,

especially when it comes to the

behavior

 of others, has become known as the "fundamental attribution error". For a long time

psychologists thought this type of error was present in all cultures. But studies

raised doubts about this assumption of universality (see Choi, Nisbett, & Norenzayan,

1999 for a review). Berry et al. (2003), reviewing the literature, concluded "it

seems the basic psychological process of attribution is present across cultures,

but it is developed and used differently, according to some features of the

cultural context" (p. 73).

In the area of culture, ethnicity, and mental illness, many relevant studies appeared

with the basic assertion that the practice of psychiatry and clinical psychology

- no matter where it is practiced - is significandy influenced by its setting (Al-Issa,

1977; Bhugra & Bhui, 1998; Castillo, 1997; Engel, 1977, 1980; Kleinman, 1980; Organitsa,

1998; Organitsa et al. 1998; Renfrey, 1998; Sue & Sue, 1987). The researchers generally

look at culture as a construct that captures a socially transmitted system of ideas

tbat specify, in highly diverse ways, "normal" behavioral patterns for a great variety

of daily needs (Hughes, 1993, p.8). Kazarian & Evans' (1998) book,

Cultural

 Clinical Psychology, can be considered a very promising breakthrough in this regard.

They proposed the term "

cultural

 clinical psychology" as a viable integration of culture into the science and practice

of clinical psychology (p.3).

In spite of these advances in general mental health practice, the impact of cultural

 studies on CBT has not been highlighted sufficiendy. Not is only culture missing

from nearly all the textbooks on CBT, it has not been included in the body of knowledge

in some state-of-the-art papers (e.g. Blackburn & Moorhead's, 2000; Goldfried, 2003).

Hays' (1995) paper on "Multicultural applications of CBT" and Vera, Vila & Alegria's

(2003) paper on "The Application of CBT in Racial/Ethnic minorities" are exceptions.

CBT AND CULTURE

The basic tenets of CBT were proposed almost four decades ago by Aaron Beck and his

group (1967, 1976, 1979). Since that time, an outpouring of research has confirmed

cognitive

behavior

 theories and supported the effectiveness and efficiency of this approach (see Beck,

1991; Dobson, 2001; Hollon, 1992, 1998; Leahy, 2004 for a review). Now CBT is recognized

as the most heavily researched form of psychotherapy, with more than 300 controlled

trials completed and many thousands of studies performed on

cognitive

-behavioral pathology in mental disorders and the mechanisms of action in this treatment

approach. CognitiveBehavior

Therapy

 is based on a pragmatic model that can be applied to a wide variety of psychological

conditions and may be used as an adjunctive treatment for medical disorders (Wright,

2004).

One issue concerning the application of CBT is that it is not a homogeneous approach.

Rather, within a broad framework, there exists a diverse set of related theoretical

orientations and clinical techniques, which arose from a multiplicity of influences

(Craighead et al, 1995; Dobson & Shaw, 1995). However, Dobson & Dozois (2001) emphasized

some commonalities, such as the time-limited nature of various

cognitive

-behavioral therapies; problem specific applications of most CBT; client responsibility

for the change process; the educative nature of CBT; and that clients learn not only

about solving their problems, but also about the

therapy process (pp. 27-9).

There are two main aspects of concern regarding CBT and culture: the first is its

emphasis on the interrelation of the individual with the environment (its behavioral

component); the second is the active role of the individual in the perception, interpretation,

and evaluation of the events (the

cognitive

 component). Both these aspects provide an excellent framework to develop relevant

modifications to its strategies and techniques in different

cultural

 contexts. But to provide a formulation for such modifications or elaborations in

non-Western societies, a well-developed culturalclinical model is necessary. Today

it is agreed that any clinical practice is always influenced by its

cultural

 setting and does not exist in a cultureless vacuum. It has been asserted that "the

most biologically meaningful stimuli and events will be socially and culturally mediated".

Therefore, the term of "

cultural

 neurobiology" has been coined (Henningsen & Kirmayer, 2000, p. 485). Culture in

this sense, is a construct that captures a socially transmitted system of ideas -

ideas that shape

behavior

, category percep- tions, and (through language) give names and thereby a putative

"reality" to selected aspects of experience (Hughes, 1993, p. 7).

One of the most important issues regarding the cultural aspects of CBT is the dual

role of a

cultural system or cultural

 model as it relates to any assessment, treatment, and change process. Any

cultural system or cultural

 model provides the therapist and client with a valuable means and context for change.

But at the same time it creates serious obstacles in learning experiences and restructurings,

which are also necessary for a change process. Any clinical psychologist working

with cultures that have not yet developed explanatory systems of the change process

should be prepared to deal with such a paradox. The author believes that the most

important step toward developing a model on applying CBT in different cultures is

to provide a relevant clinical data in this regard. These data may help the psychologists

to find a solution for the problem of paradoxical role of the culture. Therefore,

I would like to refer to some points that we have learned during our long clinical

experience. A short historical background may give a highlight to the subject.

CBT IN IRAN. A SHORT HISTORY

To study the development and advancement of CBT in Iran, we need to review the establishment

of this approach in a historical context. The first training program for behavior

therapy

 at Masters of Arts level for clinical psychology students began in 1975-1976, when

the author returned to Iran with a background of developmental/clinical psychology

from Vanderbilt University's Peabody College. Two distinguished professors, Saeed

Shamlu and Vali Okowat, American-trained clinical psychologists, began Iran's first

clinical program in clinical psychology. Each year, 8 to 10 students with undergraduate

degrees in psychology were accepted to the program and offered a Masters' degree

after three years of combined theoretical and clinical training in a mental health

facility affiliated with the Psychiatry Department of the Tehran University of Medical

Sciences. The program continued to be active from 1975 to 1980, in the Clinical Psychology

Center (CPC) of Roozbeh Hospital. During this time, the faculty reoriented themselves

toward practice and research and training psychiatric residents. The methods and

techniques used in the CPC consisted of systematic desensitization, modeling, aversive

conditioning, assertiveness training, as well as some other orientations, such as

Rogerian non-directive, and psychoanalytic techniques. The detailed program, along

with prospects and problems associated with it, has been discussed elsewhere (Ghassemzadeh,

1982, 1991, 2005a). In the latter part of 1980s,

cognitive

therapy, in a Beckian version, and cognitive-behavior therapy

, in a broad sense, were introduced by American- and British- trained psychologists.

In 1996,

Cognitive-Behavior

Therapy

 for Psychiatric Problems-A Practical Guide, edited by Hawton, Salkovskis, Kirk,

& Clark (1989) was translated into Persian and adopted as a textbook in most of Iranian

universities. Four years later, Science and Practice of

Cognitive-Behavior Therapy

, edited by Clark and Fairburn (1997) was translated into Persian. Our CBT clinic

(located on the second floor of Roozbeh Complex of General Outpatient Clinics) began

its systematic work and service in 1990. Before a patient is referred to our CBT

clinic for evaluation or treatment, s/he is interviewed and diagnosed by a psychiatrist.

Once at the clinic, the patient usually undergoes semi-structured psychological interview.

The course of illness, the role of different factors in the illness, the coping styles

of patient, the impact of the problem on patient's personal, familial, social, occupational,

marital, and academic life, as well as parameters to be changed are discussed in

one or two interview-and-assessment sessions. Clinical psychologists with an M.A.

degree do the assessment under the supervision, of a Ph.D. clinical psychologist,

who leads an educational treatment team, including two psychiatry residents. When

the general plan of intervention has been determined, the residents pursue the plan

under the psychologist's supervision. Our CBT program is an approved part of the

general psychiatry training program and is carried out with part-time schedule over

the course of nine months (800 hours of supervised practice). The patients we treat

in our clinic experience a broad range of psychological and psychiatric problems,

such as depression, anxiety with all sub-classes, personality disorders, marital

dysfunction, and non-assertiveness. Most often treatment includes

cognitive

-behavioral techniques, as discussed in books by Hawton et al. (1989), Greenberger

& Padesky (1995), and Leahy (2004). The tests that we use include: Beck's Depression

Inventory (original & revised forms) (Ghassemzadeh et al. 2005e), Beck's Anxiety

Inventory, the Hamilton Rating Scale for Depression, the Hamilton Rating Scale for

Anxiety, the Automatic Thoughts Questionnaire (Hollon & Kendall, 1980; Ghassemzadeh

et al., 2006), the Maudsley Obsessive-Compulsive Scale, Yale-Brown Obsessive-Compulsive

Scale, Compulsive Activity Checklist, Obsessive-Compulsive Inventory-R, MMPI, and

other general questionnaires.

Because a treatment plan should match the cultural

 experiences of the client, traditional forms of

therapy

, which have been developed and practiced in the Western world, are modified. I believe

that when working on the role of culture and

cultural

 constraints on psychological treatment, three basic questions must be answered:

1) What are the main resources of a culture as can be recognized and used by a practitioner?

2) How can we provide a model to generate a practical and a testable strategy to

use these resources (as well as the techniques based on such resources) in clinical

settings?

3) How can Iranian practitioners generate a formula through which the old concepts

could be defined, evaluated, and implemented in the framework of current psychological

science?

In this paper, I will discuss two resources that can be the basis for clinical psychologists

to develop their own culturally appropriate frameworks. The other questions will

be discussed in a separate article.

THE MAIN RESOURCES OF PSYCHOLOGICAL TREATMENT

I believe there are two main resources for psychological treatment in Iran that deserve

special consideration. They are: literature and familial structure and relations.

Literature

Iranian culture boasts of an ancient historical background, including outstanding

scientific and scholarly achievements that are associated with remarkable figures

in philosophy, literature, poetry, mathematics in general, and medicine and humanities

in particular. The way to talk to the patient and establish a trusting relationship

between doctor and patient, and to respect the patient's ideas and value system,

considering the patient's whole personality; all this has been stressed and highlighted

in traditional Iranian medicine. We read in Chahar Maqala (Four Discourses), written

by Nidhami-I- Arudi-I- Samarqandi (d.1147), that

The physician should be of tender disposition, of a wise and gentle nature, and more

'especially, be an acute observer, capable of benefiting patients with accurate diagnoses,

that is by being able to offer rapid deduction of the unknown from the known. And

no physician can be of a tender disposition if s/he fails to recognize the nobility

of man . . . (p. 115).

In the same book there is a thoughtful indication about a clear distinction between

physical management (medical treatment), and psychological management (psychological

treatment) (p. 114).

Here is a narration in Gulistan (Rose Garden) written by Sa'di (1184-1291?), one

of the most brilliant Iranian thinkers, poets, and writers, that shows the application

of a technique that is similar to our current flooding or exposure

therapy. Here is the entire story.

A king was sitting in a sailing vessel with a Persian shve. The slave, a boy, having

never before seen the sea, nor experienced the inconvenience of a ship, began to

cry and hment, and his whole body was in tremor. Notwithstanding all the soothing

that was offered, he would not be pacified. The king's diversion was interrupted,

and no remedy could be found. A Hakim, (a philosopher or wise man) who was in the

ship said, 'If you will command me I will silence him. ' The king replied, 'It will

be an act of great kindness. ' The philosopher ordered them to throw the boy into

the sea, and after several plunges, the sailors laid hold of the hair of his head

and dragging him towards the ship, he clung to the rudder with both hands; when he

got out of the water, he sat down quietly in the corner of the vessel. The king was

pleased and asked how this was brought about. The philosopher replied, 'At first

he had never experienced the danger of dying drowned, and neither knew he the safety

of the ship. In like manner [is] the value of prosperity who hath encountered adversity

. . .' (pp. 59-62).

These are but a few narrations from the Iranian literature.

The Family

Familial structure and function in Iran has gone through many transitions and transformations

in the course of history. As a unit, a family structure represents a multidimensional

entity, influencing economical, social,

cultural

 and psychological patterns of thoughts, behaviors, and decision making (Ghassemzadeh,

1993). Family members are connected to each other by strong emotional bonds that

manifest themselves in everyday life and when dealing with difficult or problematic

situations. The members of this interconnected system, particularly children, enjoy

unconditional, positive support from parents and other family members. Individuality

as interpreted and explained in Western culture, loses its meaning in this context.

Most Iranian parents know almost everything about their children, even about private

matters. A young person never visits the doctor or psychologist by him- or herself.

Most likely, a young client would visit the therapist accompanied by a parent, and

in some cases, an older sister or brother. This peculiarity makes the therapist ask

the family members' opinion regarding the patient's

behavior

. Without family cooperation and coordination, any treatment plan is doomed to failure.

Although this protective role of the family may sometimes cause problems regarding

autonomy, independence, and self-confidence of the children, it may be a rich source

of information for treatment planning. The patient is sure that someone is there

who cares and supports him/her in solving the different problems of life. Except

in some cases, such as the problem of reassurance in OCD patients (see Ghassemzadeh

et al., 2002; 2005d), there are good reasons to believe that the family can play

a very positive and constructive role in the management of different psychological

problems. The specific role of the family members in the implementation of CBT techniques

may be summarized as follows: 1) reminding the patient about the time of appointment;

2) providing the relevant data about the symptoms, course of the illness, the impact

of illness on the different aspects of the family's life as well as on the patient's

improvement; 3) helping the patient to do homework assignment; 4) contributing money

for

therapy

; and 5) providing a suitable and comfortable environment for the patient.

Occasionally, the family may become a source of conflict. In part, this may be related

to the family not being direcdy representative of Iranian society in terms of value

systems and behavioral standards. Internal norms of intra-familial relations may

differ from-or even contradict-external norms, which are controlled by the ruling

class. When children become aware of this contradiction, they often become confused,

but eventually resolve the problem as a member of a family rather than as a member

of a society. In our culture, one of the young generation's problems is determining

how to approach such a conflict and cope with it.

CBT IN ACTION

Except for a small group of people, who may benefit from insight-based therapies,

including psychoanalysis, the majority of our patients do not find these types of

therapy

 useful and practical. My colleagues and I found interventions that attract the clients'

attention and influence

behavior change include:

1) focusing on specific and tangible aspects of behavior in evaluation as well as

treatment,

2) assigning homework, and

3) using the "normal" part of personality as scaffolding upon which to build new

coping strategies.

Accordingly, these maximize the clients' (and their families') adherence. This experience

closely resembles what has become a hallmark of

cognitive-behavior therapy

, and it suggests that this approach to

behavior change may have a better chance to adapt itself to different

cultural variations than many conventional alternatives.

At present, because of the scarcity of controlled investigations, we know too little

about Iranian psychotherapy to identify treatments of choice or to make definitive

comparisons on the efficacy of therapeutic approaches. However, there is good reason

to believe that

cognitive-behavior

 therapists are well suited to providing culturally sensitive services to our population.

Currently, the action orientation of

cognitive-behavior therapy

 and, to some extent, its directiveness seems to be congruent with the needs, values,

and expectations of many Iranian patients. But this all depends on appropriate modifications

and elaborations, which require an intimate knowledge of the applications and specific

techniques of CBT. In the following section, I explain some of the

cognitive

- behavioral oriented strategies I have used and found useful in my clinical experience.

Motivation, Cognition, Emotion, and Behavior

An important part of therapy

 is helping patients recognize they can change something in their lives, be such

change physical, behavioral, physiological,

cognitive

, or emotional. Even the most sophisticated computers do not start operating unless

someone takes the initiative, enters data, and activates a program. Taking initiative

means to start doing something, which, psychologically, may be termed motivation.

The "motivational" aspect of

behavior

 is, in my view, the most important part of any change process and must be a focus

of care, before providing patients with direction about the differences among cognition,

emotion, and

behavior

. Of course, discussion and hypothesis testing help patients develop the skills appropriate

for solving problems, but motivation is a necessary precondition for this process.

Traditionally, we use the term aqel ("wisdom"), to include cognition, emotion, behavior

, and more aspects of human conduct. "Wisdom" means to think comprehensively, react

thoughtfully (with stable and controllable tonicity), and behave in a "normal" way.

In helping patients differentiate cognition, emotion, and

behavior

, I found the first two chapters of Greenberger & Padesky's (1995) Mind Over Mood

very useful. It takes about one to two sessions to work on this differentiation.

The rationale for using this technique is to make patients aware of the roles of

cognition (e.g. "I will not be able to solve this problem"), emotion (e.g. "how awful

is the situation"), and

behavior

 (e.g. " I just can't do it"). In some cases, however, for example in severe depression,

it is difficult or even unnecessary to make such a differentiation.

The role of attitude

When motivation has developed, the next important task is showing patients it is

possible to make a difference in their lives by changing their attitudes about their

outside and inside worlds. I usually give an example about an elementary school student

who has just learned multiplication. Using this new skill the student does not feel

compelled to add 5 +5 +5 +5 4-5 +5 to come up with 30. He simply multiplies 5×6.

Nothing "physically" changed, but a new "

cognitive

" formula made a difference in his coping skills. This formula changed his attitude.

I then explain to the patient that in CBT we learn new formulas to deal with our

problems - problems we would not be able to solve by using our existent skills.

"Either-or" philosophy

The "black-white" or "good-bad" philosophy, or thinking in absolute .terms and extremities,

is very popular in patients with depression and, I would say, normal subjects in

Iran. Flexibility in thinking is very helpful in coping with difficult Me problems.

For this purpose, I usually spend at least one session working on the analysis of

the events, which are evaluated totally as negative by the patient. The events to

be reviewed may be selected by the patient in collaboration with the psychologist

from the patient's notes and assignments. For example, one case involved a student

faced with a failure on the College Entrance Exam - which is one of main sources

of stress of young people in Iran. We discussed possible and probable aspects of

academic failure and the lessons that might be learned from such a failure. We discussed

the need to work on basic science and language proficiency, and how failure might

provide an opportunity to make him stronger and ready to cope with new experiences

at the university.

In people with "either-or" philosophy or pattern of thinking, I use a technique borrowed

from the Russian formalists' literature called defantiliarization. I use Rumi's (1207-1273)

famous verse for this purpose:

Yesterday the master with a lantern was roaming about the city,

Crying, ? am tired of devil and beast, I desire a man [a real human beingl';

They said, 'he is not to be found, we have been seeking';

One who is not to be found - that is my desire'

In this verse Rumi tries to "distract" the attention of people from "familiar" belief,

to an unfamiliar outlook. Imagine the scenario: someone is carrying a candle in the

midday claiming he is looking for a human being! The most important message of this

verse reflects the fact that the people around this man never ask why he is carrying

a candle in the light of a day, rather they fall back on a "default system" that

tells them: "You never will find such a person". But the man with the candle asserts:

"OK. I am looking for someone, who is not to be found," which changes their whole

system of looking at things (see Ghassemzadeh, 2005b, for a

cognitive

 analysis of this verse). "Either-or" people can benefit from such a technique in

searching for new meaning in what has happened to them.

No pain - no gain

It is very important to make clear that the therapeutic process is a collaborative

and mutual endeavor. It is not one-way commanding or advising. It is a joint project

with an educative nature. The didactic style of CBT helps to orient patients quickly

to treatment by educating them about mental disorders and how CBT is used to conceptualize

and treat problems. Not only does the educational approach "demystify" psychotherapy,

but also it is consistent with "role preparation", in which patients unaccustomed

to

therapy

 are taught what they can expect and what will be expected of them in the attempt

to prevent dropout and enhance treatment (Orlinsky & Howard, 1986). Emphasis on the

active role of the patient in the change process should be clarified from the onset

of

therapy

. Some patients come to our clinic with the expectation that "something will be done

to them or something will happen automatically" without any contribution from their

side. We usually make clear that the outcome is dependent mostly on the patient's

attempt "to collaborate by doing homework assignments and the instructed exercises.

Assertiveness training

Humility has been advocated as a very positive trait in our Iranian culture. For

example, in Bustan (The Orchard ) of Sa'di there is a short story about a raindrop

and the sea. This is a "monologue" of a raindrop falling from a cloud and seeing

a sea:

A rain drop fell from a spring cloud, and, seeing the wide exposure of the sea,

Was shamed. "Where is the sea," it reflected, "Where am 1? Compared with that,

forsooth, I am extinct." While thus regarding itself with an eye of contempt, an

Oyster took it to bosom, and fate so shaped its course that eventually the

Raindrop becomes a famous royal pearl.

It was exalted, for it was humble, knocking at the door of extinction, it became

Existent. (Sa'di, 1971, p. 7)

Therefore, it is necessary to refer to some delicate differences between humility

and non-assertiveness. Sometimes it is helpful to give some examples of non-assertiveness

in social situattions based on equal human rights. But in general, assertiveness

training has proven to be a very effective technique in treating patients who are

shy, have low-self esteem, are unsatisfied with their achievements, have depression,

and in some cases have anxiety. In addition to the techniques introduced in CBT textbooks,

using metaphors and poems have been useful in this regard. I use the following verse

of Sa'di on the importance of assertion, self-disclosure, and verbal discourse (Ghassemzadeh,

1999):

O intelligent man, what is the tongue in the mouth?

It is the key to the treasure-door of a virtuous man.

When the door is closed how can one know

Whether he is a seller of jewels or a hawker?

I found Hafiz, another Iranian brilliant poet's (1998) verse, also very useful:

Are thou a mote, my little one?

Be not so humble; play at love!"

And thou shalt whisper to [the] sun,

Whirling within its sphere aboveX p. 374)

I usually give these verses as a homework assignment, asking patients to read them

and write an explanation about the poems. The hypothesis is that processing the meaning

of the verses on different levels may change the patients' attitudes towards themselves.

We also found role playing very effective in assertiveness training. The scenarios

in role playing include parent- child, husband-wife, and employer- employee interactions.

In one study, Jalali & Ghassemzadeh, (1999) found that after nonassertive students

watched video scenes in which the characters were assertive, the students behaved

assertively in real life.

Exposure therapy

Exposure therapy

 has proven to be one of most promising applications of CBT in Iran (Ghassemzadeh,

1986, 1995). About 20 years ago, we had a hard time helping patients with obsessive-compulsive

disorder (OCD). But during the last two decades, new achievements in the use of selective

serotonin reuptake inhibitors on the one hand, and exposure

therapy

, along with response prevention, on the other, have opened new horizons in OCD

therapy.

We found exposure therapy

 very effective in OCD patients with obsessive handing washing (who are mainly women).

When we first tried using exposure

therapy

 techniques in one of wards of Roozbeh Hospital about 15 years ago, no one believed

that it would be effective for OCD, but the outcome showed its effectiveness.

But still we have some problems in treating patients with pure obsessions, particularly

those who obsess about blasphemy. We began to use Salkovskis' (1985, 1989; Salkovskis

et al., 1998) theory about evaluation, responsibility, and guilt feelings in OCD

patients. In one study (Ghassemzadeh, et al., 2005c) we found that distorted beliefs

about responsibility, attitude, and interpretations were the prominent features of

Iranian patients with OCD. But exposure

therapy

 for patients with obsessive thoughts is not as promising as it is for compulsive

washers. We developed a technique called Intentional Delayed Response (IDR), using

it first with patients who had trichotillomania, and then we applied it to those

with obsessive checking

behavior. This technique is based on delaying the obsessive behavior

. For example, in a patient that obsessively checks a water tap, we ask the patient

to put his hand on the tap, wait for three to five minutes, and then check it to

be sure it is off! We are going to report our data, based on clinical cases, in the

near future.

Homework assignment as an extension of the session

Homework assignments as an important part of CBT strategies require detailed explanations

and rationales. We usually emphasize three aspects of any homework assignment (or

daily workbook):

1) it regulates the patient's behavior

 through the instructions, rules and guidelines - something close to what Luria (1982)

used to call the control of

behavior

 through the outer speech of someone else,

2) it provides relevant data to discuss in the session; and most important,

3) it can be explained as an extension of the session.

In this sense, homework t functions as a mnemonic device for patients, reminding

them about the points discussed in the session with the therapist. Actually, any

assignment is an instruction, activating what happened in the

therapy

 session and indicating what will most likely happen in a future session. It is a

clue of the therapist's psychological presence in the life of the patient.

Metaphor and metaphor therapy

Metaphor as a multi-dimensional script involves many cognitive

, emotional, and motivational processes that unify different aspects of human communication

in a compact, condensed, and paradoxically, easily understood form. Metaphors, in

this sense, possess some heuristic value and play an important role in schematic

shift based on implicational meanings as suggested by Teasdale (1993) and Teasdale

& Barnard (1993). Metaphor

therapy

 was proposed by Kopp (1995, 2001) and Kopp & Craw (1998). Persian poetry as a very

rich source of metaphors can benefit CBT in many ways. In a previous study (Naziri

& Ghassemzadeh, 2004), we used patient- generated metaphors in depression treatment.

And recently, we started a project using metaphors in CBT. We found metaphor-based

CBT more effective than traditional CBT. But we need more studies in this direction.

Concluding remarks

It is time to overcome what Hsu (1976) called "culture- bound myopia", and to correct

psychologists' failure to meet the needs and demands of patients of various ethnicities

and cultures.

Cognitive- behavior therapy

 seems to have a very high potential for application in different cultures, but it

requires a clinician who is aware of culturally normative processes (Kaiser, Kats,

& Shaw, 1998). Studies of the applicability of cognitivebehavioral principles, strategies,

and techniques across

cultural

 groups and individuals would provide an empirical base from which to determine their

generality. At the same time, such studies could lead to a better understanding of

how such interventions are best tailored to different cultures. But one point should

be clarified: although the clinician's knowledge about the individual's culture can

be of help to inform about relevant

cultural factors, to effectively assess cultural

 identity, the clinician must treat each individual as a unique case, exploring directly

his or her

cultural

 identity (Castillo, 1997).

-1-

Questia, a part of Gale, Cengage Learning. www.questia.com

Publication Information:

Article Title: The Practice of Cognitive-behavior Therapy in Roozbeh Hospital: Some

Cultural and Clinical Implications of Psychological Treatment in Iran. Contributors:

Habibollah Ghassemzadeh - author. Journal Title: American Journal of Psychotherapy.

Volume: 61. Issue: 1. Publication Year: 2007. Page Number: 53+. © 2007 American Journal

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