(p. 1) Introduction
Purpose of This Book
This book describes culturally informed therapy for schizophrenia (CIT-S), a 15-week, family-based intervention for treating individuals with schizophrenia spectrum disorders (SSD) and their family members. It provides the theoretical background for CIT-S and a step-by-step guide to conducting the intervention. While several psychotherapies for schizophrenia exist (e.g., Roberts, Penn, & Combs, 2015), few systematically incorporate clients’ cultural beliefs, values, and practices into the intervention. Thus, these interventions may be less relevant for individuals from certain ethnic and cultural backgrounds. Additionally, existing interventions do not systematically incorporate family members and others closest to those coping with an SSD into treatment, despite the fact that there is evidence that schizophrenia is highly responsive to the emotional atmosphere of the family. Research suggests that sociocultural factors play a central role in adjustment to this disorder for both people with an SSD and their family members (Lefley, 1990; Weisman, Gurak, & Suro, 2014). By treating the client in isolation, without their loved ones, prior interventions may have a more limited impact on the sociocultural environment in which a person resides and operates.
Who Is This Book For?
This intervention is most relevant for clinicians and researchers interested in treating individuals with SSDs and their close family members. (p. 2)
One word of caution is that clients who are currently in the midst of an acute psychotic episode do not make good candidates for CIT-S. The rationale for this perception is discussed in more detail in Chapter 8, where we suggest that such clients should first be referred out for medication management and then encouraged to return once stabilized. In Chapter 8, we also offer guidance on how to determine if a client is currently displaying levels of psychosis too high to benefit from treatment.
We define family broadly and refer to genetic kin, romantic partners, and any other close friends who have a long-term commitment to the care of an individual with schizophrenia. While the treatment is specifically developed for individuals with SSD, it is important to point out that improving the lives of family members who care for (and about) individuals with SSDs is also an important and direct goal of CIT-S. This is different from many other family treatments that include family members in therapy primarily to the extent that they can aid in the recovery of the person with mental illness.
Thus, if you are a mental health treatment provider who works with clients with SSDs, this book may be for you. If you are a person with an SSD or a family member of one, you may also benefit from this book as a form of self-help or as an accompaniment to another psychotherapy approach. As the treatment draws heavily from clients’ own cultural, religious, and spiritual beliefs, values, and traditions, CIT-S is relevant for individuals from any race and ethnic or cultural group. There is no intention to “teach” clients about cultural and religious factors. Rather, the aim is to have clients educate clinicians about their own cultural and religious beliefs, practices, and traditions. Clinicians then utilize this information to help guide clients to create healthy and harmonious environments that are in line with their values and that, ultimately, will allow them to better manage mental illness and improve the quality of their lives.
Credentials Required to Deliver CIT-S
In our view, clinicians who deliver CIT-S should be licensed mental health practitioners (e.g., psychologists, MSWs), or doctoral students or (p. 3) master’s level students in supervision with a licensed practitioner who is qualified to deliver CIT-S. As CIT-S draws largely from a cognitive behavioral framework (e.g., Sokol & Fox, 2019), some background in this orientation is necessary. Finally, as CIT-S is a family-focused intervention, clinicians should have received some prior training in family-oriented and systems approaches (e.g., Conoley & Conoley, 2009; Lebow, 2015) or should receive supervision from someone who has the appropriate training.
Organization of the Book
In Chapter 1, we have thus far described the purpose of the book and discussed who it is intended to serve. The remainder of this chapter will outline the organization of the book. In Chapter 2, we describe the signs and symptoms of SSDs and provide the theoretical rationale behind CIT-S. Next, we provide an overview of CIT-S and describe the empirical literature supporting the efficacy of the intervention. In Chapters 3 to 7, we offer an in-depth, session-by-session guide for implementing each of the five modules of the intervention. Each module is accompanied by detailed handouts to guide that treatment segment, suggested homework assignments, and a case example to illustrate how the module can be applied to individuals from diverse ethnic and cultural backgrounds. The cases capture common familial structures including nuclear families, single-parent households, same-sex couples, and mixed-race couples. They also encompass a range of religious orientations such as Christianity, Islam, Judaism, and atheism. It is important to note here that these case illustrations are fictional. While many of the events, stories, and issues that are depicted in these cases are drawn from our experiences with actual clients in CIT-S, we have altered their names, demographics, and storylines to make sure that no client is recognizable.
In Chapter 8, we discuss working with clients who are unmedicated and displaying high levels of psychosis. We also discuss issues around whether it is important for clinicians and clients to be similar in ethnicity and other cultural beliefs and values, and we offer suggestions for dealing with challenging clients and families. Finally, in Chapter 9, we provide an integrated hypothetical case example of CIT-S that illustrates each module within a single family.
(p. 4) Glossary of Important Terms and Phrases
It is important to clarify how we are defining certain words and terms in this book. For race and ethnicity in particular, we attempted to use terms that are (a) inclusive of all individuals we are aiming to include in the definition and ideally (b) used by the group we are referencing. However, regardless of the term used, we are endeavoring to describe heterogeneous groups of people, some of whom may prefer alternative terms. In addition, concepts of race and ethnicity shift over time, so while we attempt to use appropriate terminology in this book, we recognize current and future readers may prefer different labels.
In this book, we use the label H/L to define people who identify as Hispanic, Latino/a, or Latinx. The term Hispanic comes from the Latin word Hispania, which later became España (Spain) and refers to people who are from countries where the primary language is Spanish (Salinas, 2015). This term was first adopted by the U.S. government during Richard Nixon’s presidency and was implemented in the U.S. Census in 1980 (Delgado-Romero, Manlove, Manlove, & Hernandez, 2006). The term Latino was adapted by the U.S. government to refer to people from Mexico and the Caribbean and the countries that comprise Central and South America, including those that are not Spanish-speaking such as Belize, Brazil, French Guiana, Guyana, and Suriname (De Luca & Escoto, 2012). Latino also refers to people who identify as mestizo or mulatto (mixed White, with Black and Native) people of Central or South America (Delgado-Romero et al., 2006). The term Latinx emerged much more recently as a gender-inclusive replacement for Latino/a (Salinas & Lozano, 2017). While there are certainly many subgroup differences among individuals under the H/L umbrella, they also share many commonalities including a tendency toward a more collectivistic self-construal, a strong emphasis placed on the family, and religious sensibilities that shape and give meaning to their lives (Suarez-Orozco & Páez, 2002; Telzer et al., 2010; Turcios-Cotto & Milan, 2013). Studies suggest that H/Ls, relative to other ethnic groups, tend to remain loyal to their native language and the majority, even those living in the United States, have some proficiency in and a strong connection to the Spanish language (Suarez-Orozco & Páez, 2002; Mora, Villa, & Dávila, 2006; Alba, Logan, Lutz, & Stults, 2002).
(p. 5) We use the term Asian to refer to a broad group of individuals who have origins in East Asia, South Asia, or Southeast Asia, as defined by the U.S. Census Bureau (Humes, Jones, & Ramirez, 2011). Among Asian people, the family unit tends to be highly prized and emphasized throughout the life cycle more so than in White families, in which parents and other members of the nuclear family are more likely to encourage and value independence, autonomy, and self-sufficiency of individual members of the nuclear family, especially as they reach adulthood (Lee & Mock, 2005). Common Asian values, which may be highly relevant to consider in therapy with this group, include self-control, suppression of emotion, and a short-term, result-oriented solution to problems (Lee & Mock, 2005).
We use the term White to refer to people who are of European descent who do not identify as H/L, although at times this term is also used to refer to Americans of North African and Middle Eastern descent (U.S. Census Bureau, 2011). White people in the United States have been the most resistant to ethnic labels (Giordano & McGoldrick, 2005; McDermott & Samson, 2005). However, research shows that this group of individuals does share some commonalities, including a belief system that views time as a commodity, a view of the individual as the primary unit of society, and a notion that status is best measured by credentials, possessions, titles, and professions (Giordano & McGoldrick, 2005; Lincoln, Chatters, & Taylor, 2003; Zha, Walczyk, Griffith-Ross, Tobacyk, & Walczyk, 2006).
We use the term Black to refer to individuals who have ancestry in any of the Black racial groups of Africa (U.S. Census Bureau, 2011). While the term African American is also used within the United States, it is often used in reference to Black Americans descendant from people who were brought to the Americas and enslaved from the 17th to 19th century (Agyemang, Bhopal, & Bruijnzeels, 2005). This may exclude African Caribbean/Black Caribbean individuals, which refers to people with African ancestry who migrated to the Caribbean. Although Black refers to a very heterogeneous collection of people, as a group, religion and spirituality have been particularly important factors in the lives of Black people living in the United States, with three out of every four reporting that religion is extremely important in their day to day functioning (Black & Jackson, 2005). Family structures often tend to be extended with three (p. 6) or more generations living in a home, and the role of the grandmother is often central in Black American families (Hines & Boyd-Franklin, 2005). Hines and Boyd-Franklin (2005) argue that Black individuals have very strong kinship bonds that are traceable to Africa, where various tribes shared commonalities that were stronger than bloodlines. They further contend that because Black people had the worldview that they owed their existence to the tribe, even today Black people often hold the collectivistic philosophy of “we are; therefore, I am” as opposed to the more individualistic focus from a mainstream, White U.S. perspective (Nobles, 2004). We use the terms White and Black rather than alternatives (such as Euro American or African American) because these terms are less tied to specific countries/continents than their alternatives.
It is also important to point out that, in this book, we generally do not add the descriptor American (e.g., Asian American) for any ethnic group, unless we are reporting results of a specific study (e.g., Mexican Americans). This is because, despite the fact that this book is generally intended for clients and clinicians living in the United States and many clients may be United States citizens or permanent residents, others may be visiting, reside abroad for part of the year, or simply do not identify as American. Thus, the term American does not add specificity and in some cases may be inaccurate; therefore, we chose not to include it.
It is important to note that we view race and ethnicity as primarily social constructs, as opposed to predominantly biological indicators. In this vein, we consider our client’s sense of their own race/ethnicity as much more salient in treatment than other genotypic or phenotypic characteristics (such as what they look like). Thus, in our research studies, clients’ ethnicity/race is often designated based on their own self-report of these constructs.
In the same vein, clinicians should ensure they also ask clients about their gender identity and use the pronouns that the individual endorses. Importantly, clinicians should avoid making assumptions; an individual may identify as nonbinary, but prefer he/him/his or she/her/hers pronouns or have undergone surgery to present as masculine/feminine but prefer they/them/theirs pronouns. In this book, we frequently use they as a singular, gender-neutral pronoun. For the purpose of our case illustrations, we have utilized she/her/hers and he/him/his pronouns as, (p. 7) to date, all of our clients in CIT-S endorsed these pronouns and have identified as cisgender. However, we believe the goals of CIT-S are in line with working with a multitude of identities and cultures, and we hope subsequent iterations of this clinician guide may provide additional insights that may prove beneficial to clinicians and their clients with these and/or other identities.
We use the word minority to refer to people of limited power and disadvantage rather than referring to the size of the group relative to others. This is because certain groups such as H/Ls are expected to surpass non-H/L White individuals by the middle of the century (and already have in some cohorts, such as generation Z; Passel, Livingston, & Cohn, 2012) yet are still disadvantaged in terms of economic and political power (De Jong & Madamba, 2001; Kempf-Leonard, 2007). Similarly, women outnumber men in the United States and much of the rest of the world, yet financially, professionally, and in other ways (e.g., holding powerful political positions) still fare more poorly than their male counterparts (Le & Miller, 2010; Lawless & Pearson, 2008).
When we discuss religious groups (e.g., Muslims, Christians, Jews), we are generally referring to a group of individuals who may be from any ethnic-cultural or racial background. Of course, this line is sometimes blurred. For example, Jewish identity has been historically grounded in both genealogical and religious heritage (Glenn, 2002), and to the extent a Jewish individual identifies with one or both of those aspects can influence their sense of self (Friedman, Friedlander, & Blustein, 2005; Hecht & Faulkner, 2000; Weisskirch, Kim, Schwartz, & Whitbourne, 2016).
With respect to the terms religion and spirituality, we generally use the term religion to refer to specific creeds, rituals, sacraments, etc. that are associated with an identifiable faith. On the other hand, the term spirituality will be used more often to refer to one’s quest for meaning and belonging and to the core values that influence one’s behavior, which are not necessarily tied to a specific doctrine or canon. Occasionally, we use the abbreviation R/S when it is difficult to separate the concepts, as some scholars argue that they cannot be unlinked. Zinnbauer and Pargament (2005), for example, place spirituality within the broader construct of religion. They suggest that spirituality serves as the core of religion, with religion referring to a broader range of behaviors than does the term (p. 8) spirituality. Koenig (2012) similarly argues that spirituality is an extension of religion, where those who report themselves to be at the highest levels of religion are considered spiritual. In this book, therefore, when we are making no distinction, we will use the abbreviation R/S, but will continue to separate the terms otherwise, as previously described.
Finally, we use the word intersectionality to refer to the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group. Overlapping and interdependent identities can lead to more complex forms of discrimination and disadvantage in some cases. Having multiple identities can also impart unique and compounded strengths, as people have a greater number of experiences, value systems, and often resources to draw from, which can assist them in managing mental illness and other adversities.