Responsibility and Cultural Adaptations in Psychotherapy
Who Am I
María Celeste Airaldi is Director of the Sensorium Institute, in Paraguay, a center specialized in psychology, and is a professor at the Catholic University "Nuestra Señora de la Asunción", also in Paraguay; she is also a Level 2 Faculty Trainer at the Albert Ellis Institute in New York.
She was trained as a clinical psychologist at the "Nuestra Señora de la Asunción" Catholic University. She is specialized in effective techniques in psychopathology, by the University of Favaloro, in Argentina. Subsequently, she began her training in rational emotional and cognitive behavior therapy (RE&CBT) at the Albert Ellis Institute, in New York, where she reached the level of faculty trainer, which is the level to certificaty and supervise therapists in training. In addition, she is a doctoral candidate at the University of Palermo, in Buenos Aires, Argentina. She has trained and supervised REBT and CBT trainings all over Latin-America and she also works as a psychotherapist at Sensorium. She is the current vice-president of the Latin-American Federations of Cognitive and Behavioral Psychotherapies (ALAPCCO).
What Psychotherapy Means to Me
For me, doing psychotherapy is, first, a tremendous responsibility, because we assume that the vast majority of people who come to us are people with some kind of problem, who are having a hard time, and have trusted us to help them along that path. I think psychotherapy has to do with being able to individualize the scientific protocols; that is, the evidence-based treatments are manualized, and we need to make them work to the one who is sitting in front of us. So, I understand it as the approach of science to the individualities and particularities of the client in front of us.
Why Did I Choose to Work with CBT and REBT
Doing a bit of history, a phrase that Eduardo Keegan said comes to mind. He is is a great psychologist and one of the pioneers in CBT in Argentina, and who was one of my professors at University of Favaloro and my current colleague at the ALAPCCO’s board. He said something like “I don't believe that a person becomes a cognitive behavioral therapist, I believe that one already has that way of doing therapy and then discovers the model and the form." That made a lot of sense to me at the time. My first contact with CBT was not in the undergraduate school. At the university we do have to do a thesis at the end at that time, I chose to work with quality of life in post-mastectomy women and, back then, everything published on psycho-oncology in breast cancer was CBT-based. That's when I said “wow! This makes too much sense to me and I want to learn more”. That is when I decided to learn more about CBT. I searched training options and there were not much in Paraguay at that time. So that's when I had the opportunity to go to Buenos Aires to study.
Why Do I Practice CBT and REBT
What I think today keeps me attached to the model, among many things, is the fact that it is still the Gold Standard in psychotherapy treatments. So, if we go back to the matter of the responsibility that psychotherapy implies, it seems to me that we have to offer the best we have, but knowing it is an imperfect service and not suitable for everyone. I don't think I am a fan of either CBT or REBT, but I do believe myself to be an advocate for evidence-based therapy. If something else appears tomorrow and works better, then I will study something else if continue working in psychotherapy. So, more than anything, what made me practice CBT and REBT is the fact of knowing what works best and that we have more certainty of the quality of what we are offering to the person who trusts us.
I don't know if it makes sense; but it is not because I liked it more, it is because I believe that there is a tremendous responsibility in what we do. Something that everyone asks their professors at some point in the university is “what approach do you recommend I study… because I want to be a clinician”, and the vast majority of professors here answer: “the one that convinces you the most, the one you like the most ”And I make an analogy with medicine: am I going to want the treatment, the antibiotic that works best for my infection, the one from the laboratory that the doctor likes the most or the one that suits their stomach better? No! So that's why I think it must be what has proven to work best. Is it different in psychotherapy? I do not think so.
Why Do I Like and Teach REBT
Ellis was not satisfied with the type of therapy that he had been taught because he believed that the process took a long time and that not all clients achieved improvement. Then, he begins to develop his own model that today we know as REBT. The interesting thing is that, unlike more current models, REBT was born in practice with real clients and then went to the academic field to see if it worked. So, this is important. Why? Because most times treatments are born in academic environments and then they go to the clinician’s office. And what happens? They are not the same clients. The clients we see in private practice have multiple comorbidities, with chronic problems; they are not the perfect sample for research and that is why we are returning to transdiagnostic models to try to help clients in real world. And REBT does exactly that: it works with many types of disorders and in subclinical problems in a transdiagnostic way.
For example, in my experience, REBT, works particularly for two main situations: One, in clients who have multiple comorbid conditions; and second, in what is particularly useful, is in patients who are having to go through adversities, through bad life situations. It seems to me that it is useful, because when I take a closer look at their core beliefs and dysfunctional behaviors, I am not attacking the symptom but the manifestation of that problem; and that allows me to tackle the basis of the problem. That is the transdiagnostic approach of REBT.
What is Different in REBT
By having a strong base of stoicism, REBT prepares the client to face adversity; We do not start from the premise that all patients distort reality and that only because of depression they see life as bad. Of course, there are such cases, but there are many clients who have bad contexts and realities: the diagnosis of a chronic illness, death, job loss, or all together! To these clients, with the foundation of stoicism, what we do is prepare them for the worst possible scenario and understand that, as much as all this happens together, that does not define them as a person. And the focus is not only on symptom relief but also on developing a new philosophy of life to deal with frustrations. In fact, Ellis has written quite a bit about the approach to chronic pain, complex diseases and frustration intolerance.
Do I Need Any Special Requirement or Equipment to Practice REBT?
No special equipment or materials are required to implement this therapeutic approach ... the magic instrument, I believe, that we all have in the office is a white board. Because REBT is a very didactic therapy and the ultimate goal is that, in addition to developing this new philosophy of life, you become your own therapist; Or as I always tell clients: “I can be an expert on depression, but no one is more expert on your problem than you, so, let's work together!”
We use a lot of boards and notes, making it graphic and didactic, so that the clients can follow it up. When they are in online sessions, I have can use a small white board where I make notes to them or I can share my screen and I make notes on the computer.
I think that if we have a useful element that we work a lot with, it is really the board. But if you really want to train in REBT and climb the certification ladder, you will need, at some point in your training, a voice recorder, which can be your own cell phone because there comes a time when you will need to have your sessions supervised.
Another interesting material, remembering that REBT is very didactic, are the several handouts and workbooks prepared for clients, mostly in English.
Does REBT Have Limitations?
As all other psychotherapies, it does. Because it is a cognitive behavioral model, we need the client, in some way, to have cognitive material to work with. We can work with someone who has a mild intellectual dysfunction, but with a person who has a moderate to severe intellectual deficiency or dementia, they may benefit from other approaches.
But even so, there are adaptations for virtually all problems; for clients with anger, personality disorder, anxiety, depression, eating disorders, substance abuse, there is even a whole protocol called Smart Recovery which is like a specific “step by step” of REBT for addictions; then, there are protocols and approaches for different types of pathologies and ages.
How to Evaluate if the Client is Improving?
I must say that it is basically through frequent monitoring. When the client is admitted, before their first session, we do an evaluation for baseline. A general psychopathological screening, including Lambert’s OQ.45 (Outcome Questionnaire OQ-45.2) to see the initial state and depending on the reason for consultation, it can be a test of depression or anxiety or whatever is needed. I know that, especially in the United States, it is frequent do to weekly assessments, but in Latin America, if one asks the clients to do it every week they will complain. That is why I usually do evaluations once a month to quantify the improvements and to check when it is time to space the consultations and what I should work on.
Undoubtedly, the phenomenology experience of the patient is important. Something that I like to do in the first session is I ask them what are the topics on which they would like to work, what objectives they would like to achieve; let’s say start working, have a better relationship with their partner, study… and then make them operational in behavioral terms. Every so often I go over those goals. An example, a few days ago, doing this exercise with a client I told her: "Look, when you started you said that you wanted to achieve this, this, this and this." She looked at me and said: “Wow, I achieved all that! I hadn't realized it ... I didn't remember that I had set this as a goal of therapy, and I would say that they are all achieved ... "I said Ok, is there something else you would like to work on or are we ready to continue on your own?
So, it seems to me that this phenomenological and subjective experience of the client is also a way of demonstrating efficiency; Although we know that it is not objective evidence, but if we manage to make the objectives operational, it makes it easier for the client to see improvements. Especially, for example, in clients with severe depression or with personality disorders, the changes may be slower. It has happened to me that clients tell "look, everything is very nice and wonderful, you helped me a lot, but I do not think it is working for me, I am going to end treatment". So I check my notes, and I tell them “… when you first came your depression test was this high and you said this and that, a month later it was this high, and so on …. A client once said to me: Did I say that? Because if I did say it, I was really bad and I did improve a lot! I will continue treatment then”. Sometimes they are not aware of small changes, and that is why it is important to quantify them and have a very updated client registry.
Sometimes it even happens that, REBT being a brief therapy focused on core beliefs, there are relatively rapid improvements, but they must be maintained over time to really restructure those beliefs. So, two months go by, and the patient says: “oh, next week I won't be able to make it”, and then they come a month later and tell you: “oh, I was good, but not so good, I need to go back!”. Sure, you must keep working to make real change. So, this whole part of psychoeducation, is quite a challenge.
Is There a Minimal Number of Sessions in REBT?
In this therapeutic approach there is no typical or forced number of sessions that the clients must have. There is even a protocol by Windy Dryden, who is the most prolific author in REBT today with more than 250 books published, called "Single Session Therapy". A one REBT- session treatment!. There is no mandatory number of sessions, it can be only one, or as many as the client needs.
How is Psychotherapy Regulated in Paraguay?
In Paraguay, we recently passed the Law of Professional Practice of Psychology. It was approved in 2019 and regulated in 2020. It requires to have a professional registration issued by the Ministry of Health and certain conditions to be able to call yourself a psychologist and a psychotherapist. It should be mentioned that this Law is federal, it applies to the entire country, both in public and private spheres, to anyone who has a degree in psychology. Although, the regulation of this law, still, is quite soft, in some things. What we do not have yet is a large regulatory framework for controlling its application.
In addition, there is no certifying body for psychologists. In Paraguay, to practice as a psychologist it is enough to have an undergraduate degree in psychology and then the Ministry of Health gives the Professional Registry or license to work in Psychology. In order to practice, I must have a Professional Registry by the Ministry of Health. Thus, the Ministry of Education regulates academic plans, and the Ministry of Health validates those plans and grants the license to practice psychology.
It is not mandatory to have a certificate as a psychotherapist: one can practice psychology without supervision; the bachelor's degree is enough. Supervision and postgraduate training, like a master's degree, are not mandatory to practice psychotherapy. So, that means that it is up to each one of us to have training in psychotherapy... and here comes again the question of responsibility.
The Paraguayan Society of Psychology strongly advocates the existence of a certification and was the one that advocated for the approval of the law and others; but today it does not have a power of tuition. In other words, that I can call the Ethics Committee of the Paraguayan Psychology Society and inform about negligence or unethical practices, but they do not have that legal power to intervene.
In addition to these conditions that limit the regulation of the quality of psychotherapy, there are other conditions that, although they are not legal, do affect the proper use of this therapeutic approach and that are typical of our Paraguayan culture.
Cultural Considerations When Doing Psychotherapy in Paraguay
In the United States, the person who goes to the psychotherapy goes in search of a service; there is a professional relationship assumed by both parties. In Latin America we still have this view that I go to psychotherapy because I am weak or because I cannot go through things alone.
We must make some adaptations of REBT for Paraguay and other countries in Latin America but, specifically for Paraguay, it is that when speaking of a cognitive and behavioral model, we have to consider cognitive development. According to UNESCO, the abstract thinking of the Paraguayan is below the average; so that implies much more concrete and more linear thinking; so, Socratic questioning does not always work for all clients, especially in the initial stages of treatment. Sometimes, one must be much more didactic and concrete than Socratic, and gradually shifting to a more abstract and Socratic therapeutical style. That is one of the main adaptations we need to consider.
Another very particular issue is that, well, Paraguay is officially bilingual; Guaraní is an ethnic language. 50% of the population is only Guaraní speaking and up to 80% speak what we call “jopará” which is a “Spanishized Guaraní” … jopará means “mixed” in Guaraní. Guaraní is a language that has a lot of emotional expressions, and that it is why is common that even clients who do not have Guaraní as their main language expresses emotions in Guaraní. A very common example is when we ask “How do you feel today?” the answer is “I'm super kaigue”. Kaigue means feeling down, but also a mixed state of apathy, without energy and reluctant to do much. That is why you have to know the most common words that describe emotional states in order to bond with the client. I do not speak Guaraní well, but I do understand, that is why it is important for me to handle everything that has to do with emotional expressions.
The other thing that we need to work a lot, but I must say, lesser than a few years ago, is the idea that we, as psychotherapies, don't solve the client’s problem: the problem is solved by them. It requires a lot of psychoeducation about what psychotherapy is and does, and what it is not. It is not unusual to hear things like "I don't believe much in psychology or psychotherapy”. And we have to begin by explaining it is not about faith, it's science.
Explaining to the client that they are going to need to do homework between sessions is important, because there are clients who say: "No, I don't come for that, I come to talk, and I want you to just listen”. And until they do not understand how the process really work, they won’t do their part. Today, at our center, we use social media to help in the psychoeducational process, including explanations on what it and what it is not psychotherapy, and that is why I believe we are receiving more determined and informed clients, because they already know what they are going to look for and what they are going to find.
Another aspect that we must consider with our clients in Paraguay and in Latin America, is what has to do with religion. Our countries are strongly Catholic so it is common for clients to bring that topic to the session. Obviously, it is not the therapist who brings it to the session, but many times, you have to incorporate issues related to religion. Particularly in the city where I live, a border city, there are many immigrants. There is a very high percentage of Muslims and Asians, so I had had to learn about different religions and cultural backgrounds, because I need to understand the values through which they look at life. So, religion is something that usually comes to consultation a lot, too.
A Recommendation for My Psychotherapy Colleagues
I will share something that I always say to my students, they say that it is my quote... “there is no “everylogy”, there is psychology”. That means there is no approach, no matter how good and effective, that works for everything and everyone. I think that within that question of responsibility that we talk about so much, I also have to know what is the limitation of the approach that he used, and what are my personal limitations. Knowing what I can do and what I cannot do, in terms of the technical and in terms of the human; in the sense that there may be some kind of personal matter, in particular, that prevents me from being impartial. For example, sensitive topics such as abortion, infidelity, homosexuality, deaths, diseases could be delicate for some clinicians at some point of their carrier. And that is why we need to ask ourselves “do I know my limits? Which topics of type of clients are over my abilities? Are there topics that may activate my own beliefs, preventing me from being objective with this client? I believe that we must identify these limits as soon as possible. Within technical limits, one can study and work on them if we want. For our limitations as humans, first, get to know them, accept you are fallible and try to make it better whenever possible.
Cite This Article
Airaldi, M. (2022). Responsibility and cultural adaptions in psychotherapy. Psychotherapy Bulletin, 57(1), 7-12.