1. Jonathan Kanter, Ph.D. University of Wisconsin-Milwaukee Strategies for Delivering Behavioural Activation in Diverse Communities

2. Empirically demonstrate need for adaptation NIMH policy: Assume culture matters Develop adaptations of treatment for various cultural groups

3. Empirically demonstrate need for adaptation NIMH policy: Assume culture matters Problem: Results in too many cultural adaptations, not viable at public health level

4. Empirically demonstrate need for adaptation NIMH policy: Assume culture matters Problem: Results in too many cultural adaptations, not viable at public health level

5. Empirically demonstrate need for adaptation NIMH policy: Assume culture matters Problem: Not a progressive or fair solution

6. Empirically demonstrate need for adaptation NIMH policy: Create more “culture- neutral” treatment Our solution: Create culturally flexible version of BA by removing mainstream cultural elements from it

7. Empirically demonstrate need for adaptation NIMH policy: Train culturally competent clinicians Problems: Again, need to learn lots of content May encourage stereotyping, does not teach clinician how to adapt to the individual

8. Train how to assess client’s local cultural world NIMH policy: Train culturally competent clinicians Our solution: Train process of assessing and working in client’s local cultural world Specific cultural content is still important and can be trained locally

9. BA Training Sequence I Cultural competence process Providing the RationaleAssessmentActivity Scheduling Dealing with Avoidance II Functional AssessmentSkills trainingStimulus control Contingency management Dealing with Avoidance III Behavioral case conceptualization Thinking functionally about behavior

10. BA Training Sequence I Cultural competence process Providing the RationaleAssessmentActivity Scheduling Dealing with Avoidance II Functional AssessmentSkills trainingStimulus control Contingency management Dealing with Avoidance III Behavioral case conceptualization Thinking functionally about behavior

11. Cultural Competence Process “Shifting Cultural Lenses” model of Steven López, University of Southern California Develop a Shared Narrative

12. Assess client’s view Ask client what hopes to gain from tx Ask what client views as problem Assess how client fits cultural patterns Show understanding without challenging Present own perspective Introduce BA as personal view, not fact Ask for feedback, clarify Ask how view fits client’s understanding SN: Integrate Fit client’s narrative into BA model using his/her language (see next) SN: Ask for buy-in Ask client to try model with respect and collaboration SN: Negotiate Demonstrate willingness to drop BA model

13. Assess client’s view Ask client what hopes to gain from tx Ask what client views as problem Assess how client fits cultural patterns Show understanding without challenging Present own perspective Introduce BA as personal view, not fact Ask for feedback, clarify Ask how view fits client’s understanding SN: Integrate Fit client’s narrative into BA model using his/her language (see next) SN: Ask for buy-in Ask client to try model with respect and collaboration SN: Negotiate Demonstrate willingness to drop BA model

14. Assess client’s view Ask client what hopes to gain from tx Ask what client views as problem Assess how client fits cultural patterns Show understanding without challenging Present own perspective Introduce BA as personal view, not fact Ask for feedback, clarify Ask how view fits client’s understanding SN: Integrate Fit client’s narrative into BA model using his/her language (see next) SN: Ask for buy-in Ask client to try model with respect and collaboration SN: Negotiate Demonstrate willingness to drop BA model

15. Assess client’s view Ask client what hopes to gain from tx Ask what client views as problem Assess how client fits cultural patterns Show understanding without challenging Present own perspective Introduce BA as personal view, not fact Ask for feedback, clarify Ask how view fits client’s understanding SN: Integrate Fit client’s narrative into BA model using his/her language (see next) SN: Ask for buy-in Ask client to try model with respect and collaboration SN: Negotiate Demonstrate willingness to drop BA model

16. Assess client’s view Ask client what hopes to gain from tx Ask what client views as problem Assess how client fits cultural patterns Show understanding without challenging Present own perspective Introduce BA as personal view, not fact Ask for feedback, clarify Ask how view fits client’s understanding SN: Integrate Fit client’s narrative into BA model using his/her language (see next) SN: Ask for buy-in Ask client to try model with respect and collaboration SN: Negotiate Demonstrate willingness to drop BA model

17. Assess client’s view Ask client what hopes to gain from tx Ask what client views as problem Assess how client fits cultural patterns Show understanding without challenging Present own perspective Introduce BA as personal view, not fact Ask for feedback, clarify Ask how view fits client’s understanding SN: Integrate Fit client’s narrative into BA model using his/her language (see next) SN: Ask for buy-in Ask client to try model with respect and collaboration SN: Negotiate Demonstrate willingness to drop BA model

18. 18 NEGATIVE LIFE EXPERIENCES “THREE CIRCLES” Shut down, give up Procrastinate Stay at home Stop functioning Sleep too much Ruminate Drink too much Watch tv Response (Natural, common) Avoidance Pattern (Natural, common) Feeling sad, down, depressed Loss of interest or pleasure in things Stress, headaches, pain, fatigue, anger, irritability Spiritual questioning/doubts Guilt and shame Changes in sleep and appetite Difficulties with concentration and memory Use clients’ descriptions No need to educate about “symptoms” of depression

19. 19 NEGATIVE LIFE EXPERIENCES “THREE CIRCLES” Response (Natural, common) ACTIVATION Use your strengths and social support to stay active, reengage in life, solve problems Activate religious coping as appropriate Incorporate family in activation Free, low cost activities Use community resources

20. 20 Improved Life “THREE CIRCLES” Response (Natural, common) ACTIVATION

21. 21 “THREE CIRCLES” MODEL OF BA Did the therapist… 1Identify and discuss negative life experiences? 2Identify and discuss emotional responses (feelings)? 3 Identify and discuss behavioral responses (actions, secondary coping, avoidance)? 4 Validate emotional and behavioral responses as natural, normal, common (matter of fact)? 5Discuss how responses lead to more negative life experiences? 6 Explain the goal of BA: activation as alternative to natural responses (“breaking the cycle”)?

22. Challenges when Presenting the Rationale 22 Just DO IT! Validate that activation is harder than people think Discuss that therapist will coach, guide with strategies to help activation Inside Out Validate that inside-out is common and makes sense Offer rationale for outside-in approach in BA Broken Brain Validate many causes of depression Explain how activation can change the brain

23. Challenges when Presenting the Rationale 23 Just DO IT! Validate that activation is harder than people think Discuss that therapist will coach, guide with strategies to help activation Inside Out Validate that inside-out is common and makes sense Offer rationale for outside-in approach in BA Broken Brain Validate many causes of depression Explain how activation can change the brain

24. Challenges when Presenting the Rationale 24 Just DO IT! Validate that activation is harder than people think Discuss that therapist will coach, guide with strategies to help activation Inside Out Validate that inside-out is common and makes sense Offer rationale for outside-in approach in BA Broken Brain Validate many causes of depression Explain how activation can change the brain

25. Challenges when Presenting the Rationale 25 Just DO IT! Validate that activation is harder than people think Discuss that therapist will coach, guide with strategies to help activation Inside Out Validate that inside-out is common and makes sense Offer rationale for outside-in approach in BA Broken Brain Validate many causes of depression Explain how activation can change the brain

26. Questions Practice