The Development of Cognitive Behavioral Therapy: Practice, Research, and Future Directions in Latin America.

Although Latin America countries are similar in many aspects, psychology has evolved in different ways, according to the characteristics related to politics, economics, and culture of each country. This is the context in which CBT has spread through the region since the 1980s. This article aims to offer a brief historical overview of CBT development in Latin America and the challenges of its current practice. The inclusion of CBT in undergraduate and graduate studies of psychology, the therapists training programs, cultural challenges, and the CBT ​​research were discussed in this paper. All things considered, the main challenge of CBT in Latin America is to constantly reaffirm the scientific foundations of the theory and to continue to work in the scientific production of knowledge and its dissemination. © Springer Nature Switzerland AG 2021.

Introduction

Latin America is a region of the American continent that includes a lot of countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, El Salvador, Ecuador, Guatemala, Guyana, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Dominican Republic, Uruguay, and Venezuela. Given the fact that it is a large region, it is difficult to provide a homogeneous characterization (Neufeld and Carvalho 2017).

Mendoza (2017), however, points out some common characteristics among Latin American countries that have impacted the scope of psychotherapy in the region. One of those aspects is the dependent character in which Latin American psychology has developed, with a passive attitude of replicating foreign knowledge, that does not consider cultural aspects for its effective adaptation. Another outstanding feature is the social inequality and prevalent poverty in Latin America that minimizes both access and dissemination of psychotherapeutic practice. Further, religious counseling, which is commonly the first choice for treating psychosocial discomfort and mental health.

Finally, Mendoza (2017) points out the limitations of clinicians, who, in general, do not have much specialized and supervised training, together with the mistaken social representation that there is no need to seek further training in CBT because it is easier than other psychotherapies. Neufeld and Carvalho (2017) highlight the backward impact that Latin American military governments of the 1970s had on research and on the introduction of evidence-based psychological approaches. These aspects, although general, occurred with more or less intensity in different countries.

Among the differences, some aspects are very specific to each country. Most countries have Spanish as the official language, although colonization was conducted by the kingdoms of Spain, France, and Portugal. Brazil, with Portuguese as its official language, is an exception. These aspects, associated with the economic realities of each country, generate different possibilities for investment in education, technology, and science. This has a direct impact on the quality of life and health of people in each country. Therefore, even though CBT has proven scientific effectiveness for numerous psychological problems, the great diversity of characteristics present in Latin American countries requires that the application of CBT principles be adapted to these differences. Cognitive behavioral therapy began to gain prominence in Latin America in the 1980s, but this did not happen in all countries in the same time and the same way. The development and dissemination of the approach took place in different stages, with considerable differences between countries (Organista and Moñoz 1996).

This article aims to offer a brief historical overview of the development of CBT in Latin America and the challenges of current practice and research in the area. Throughout the text, we shall present some examples from specific countries. It is important to emphasize that the information contained in this paper was collected from a bibliographic survey about the CBT dissemination in Latin America. Thus, it reflects the information collected from some countries in the region. Despite this limitation, we believe this paper offers a valid perspective on the state of CBT in the region, but naturally, it cannot be considered a final portrait of all the diversity that CBT in Latin America encompasses.

The History of CBT in Latin America

The 1980s was characterized by an increase in psychotherapeutic approaches that were focused on personal changes (Prochaska and Norcross 1982). Besides that, the growth of the cognitive sciences significantly fomented the development of approaches more focused on problem-solving. Thus, CBT has grown in the USA, Europe, and in countless countries around the world.

At that same time, the political and economic history of Latin American countries in the last four decades has had many commonalities. Most countries passed through to experiments of free-market reform under dictatorial regimes in the 1970s and 1980s. At this moment, psychology was strongly affected, with courses canceled and with curriculum restricted. Military dictatorships ended in most countries in the mid-1980s. The end of this political regime allowed universities to resume their growth again, as well as the development of numerous professions (Neufeld and Carvalho 2017).

These historical processes of Latin America, associated with worldwide scientific development, led to the CBT dissemination in Latin America in the mid-1980s. The progress of CBT in Latin America was reflected in the growing interest of many professionals, who started grouping together and learning about CBT (Neufeld and Carvalho 2017).

In addition to the aforementioned political issues, an initial spread of behavioral therapies was common in Latin America. In Colombia, for example, the experimental analysis model was quite widespread between the 1970s and 1980s. This was essential for the later interest in CBT (López et al. 2006).

The creation of new associations was an important turning point for CBT dissemination in many countries. In Argentina, where behaviorism had had no significant academic or clinical impact, two groups became interested in Beck’s cognitive therapy during the 1980s. A national association for cognitive therapy—Asociación Argentina de Terapia Cognitiva—was created in 1991, and it soon joined the International Association for Cognitive Psychotherapy (Korman 2016).

In Brazil, the first representative organization of CBT was the Associação Brasileira de Terapias Cognitivas Construtivistas (ABTCC), created in 1996. Soon after, the Sociedade Brasileira de Terapias Cognitivas (SBTC) was founded in 1998, as a result of the unification of ABTCC and SBTC. In 2009, with the constitution of regional associations in the different States of Brazil (Associações Estaduais de Terapias Cognitivas—ATCs), SBTC turned into a Federation of Associations and individual members named Federação Brasileira de Terapias Cognitivas (FBTC) (Neufeld et al. 2015).

Uruguay also has a strong CBT association: the Sociedad Uruguaya de Análisis y Modificación de la Conducta (SUAMOC). It was founded in 1985 by a group of psychologists and psychiatrists trained initially in behavioral modification and afterwards in cognitive behavioral psychotherapy that had the important role to offer specialized training in different scientific streams (Lagos 2002).

Notwithstanding, in some Latin American countries, the creation of a CBT association is much more recent. In 2014, the Panamanian Institute of Cognitive-Behavior Therapy (IPTCC) was officially formalized, which was considered an important step to strengthen the approach in the country (Manieri, 2014). In the same year, Paraguay created the Asociación Paraguaya de Terapia Cognitivo Conductual (APTCC).

Given the above, many countries in Latin America already have national CBT associations such as Argentina, Brazil, Chile, Ecuador, Panama, Paraguay, Uruguay, Venezuela, and recently Peru. In other countries, “working groups” vigorously disseminate CBT, such as Bolivia, Colombia, Costa Rica, Guatemala, and Mexico (ALAPCCO 2020).

In addition to the associations created in each country, CBT is also represented in Latin America by international associations. The Asociación Latinoamericana de Análisis y Modificación de la Conducta (ALAMOC) was founded on February 19, 1975, in Bogotá, Colombia. It is a non-profit entity, and since its inception, until the present, it has become an association of professionals from Latin American countries interested in behavioral sciences and these days in cognitive behavioral therapies too (ALAMOC 2020).

After the creation of the Argentine Association of Cognitive Therapy, colleagues from Brazil, Chile, and Uruguay were invited by to participate in the first regional symposium in Buenos Aires, Argentina, in 1996. This was the first step of the Force Task whose aim was to create a Latin American Federation. The main objective of the meeting was to stimulate spaces for theoretical and clinical exchanges and for the CBT dissemination, since the only Latin American association existing at that time, ALAMOC, was more exclusively identified with the behavioral approach at the time (Neufeld and Carvalho 2017).

By this integration between the countries, after several actions, meetings, and symposia, the Federación Latinoamericana de Psicoterapias Cognitivas y Conductuales (ALAPCCO) was formalized in 1999, even though it existed and had worked actively since November 1, 1996. Thereafter, ALAPCCO has remained faithful to its mission and initial objectives: to promote the “dissemination, education and scientific research related to Cognitive and Behavioral Psychotherapies in Latin America” (ALAPCCO 2020).

CBT dissemination among new therapists is recent in most countries in Latin America. In Brazil, Argentina, Colombia, and Panama, CBT content is already present in undergraduate programs of a significant number of universities. According to the study by Neufeld et al. (2018), most of psychology undergraduate programs in Brazil offer subjects about CBT. Similarly, in Argentina, the inclusion of CBT in undergraduate and graduate studies of psychology at the Universidad de Buenos Aires (UBA) in the late 1990s was arguably a turning point for the dissemination and legitimization of the approach, since UBA is the largest and most prestigious university in the country (Korman 2016). In Colombia and Panama, CBT is also present in undergraduate programs at renowned universities such as Universidad de la Sabana and University of Panama, respectively (López et al., 2006; Manieri, 2014).

On the other hand, in some countries, such as Chile, cognitive behavioral approaches have spread “cautiously” among students and professionals. However, there have been some initiatives, such as a large-scale mental health program of the Chilean Ministry of Health, in the 2000s, which favored the dissemination and production of local material, such as the development of the intervention manual for group therapy in CBT (Vera-Villarroel et al. 2006).

Research and training programs have also grown in Latin America. Specialization courses in CBT are offered at universities, private institutions, and associations in several countries. Scientific development has also had a relevant growth in many countries (Neufeld and Carvalho 2017).

Numerous efforts and progress have been made in the last decades to provide a broader and faster CBT dissemination in Latin America. Illustrating the expansion of the model, mindfulness and acceptance-based behavioral approaches became popular in the second half the 2000s. Training in dialectical behavior therapy, mindfulness-based stress reduction, and acceptance and commitment therapy captured the interest of many psychotherapists, mostly those already trained in CBT (Korman 2016).

This brief overview of CBT history in Latin America reinforces the idea that CBT has been increasingly accepted in the region but with different scope and dissemination in each country. In this way, it is possible to identify some countries in Latin America where CBT training is widely offered, while in other countries, there are still occasional and limited offers. However, constant expansion of the model is evident all over the region.

Cultural Characteristics That Influence CBT in Latin America

Latin America is a region that has some similar cultural characteristics, as mentioned at the beginning of this article. On the other hand, there are specific local aspects to each country, such as food, clothing, and language. Besides, there are several subcultures in each country, strengthening the multicultural diversity present in Latin America. Therefore, each country must evaluate the necessity to adapt CBT concepts to their specific characteristics. Perhaps the passive attitude of dealing with knowledge, as pointed out by Mendoza (2017), and the few resources allocated to research in most Latin American countries may characterize some challenges to the inclusion of cultural factors in scientific production and clinical practice. Even so, to a greater or lesser extent, research has been carried out on the applicability of CBT in specific cultures in Argentina (Korman 2016), Brazil (Neufeld et al. in press), and Colombia (López et al. 2006), for example.

Close interpersonal relationships are a hallmark of Latin American culture (Mendoza 2017), which favor closer relations. For example, Argentinians score higher on individualism and collectivism and have a smaller interpersonal distance with their therapists than their American counterparts (Korman 2016; Facio 2017; Facio et al. 2017). Even though, the research conducted by Neufeld et al. (in press) with a Brazilian sample of therapists points out that interpersonal relationships in therapy sessions are affectionate, empathic, and not very assertive, making it more difficult to take a directive stance and to give feedback. Thus, in general, relational aspects stand out as a Latin American characteristic that must be taken into account when applying CBT.

Another characteristic that seems to be common in Latin America is flexibility in the use of CBT protocols. Korman and Sarudiansky (2020) highlight that Argentinian CBT therapists usually seek CBT for themselves, apply CBT conceptualizations to treat other problems than mental disorders, and will extend the duration of their interventions beyond the length of protocol if they believe this is beneficial for their clients. The research conducted by Neufeld et al. (in press), in two focus groups with Brazilian professors and therapists, pointed out that (a) patients have difficulties on following the CBT structure because of not dealing well with strict rules and (b) therapists intensively use flexibility and creativity in therapy, which may interfere in the structure and protocols used. These results are supported by a Brazilian cultural and behavioral identity, known as “Jeitinho brasileiro,” as well as its impacts on the perception of what can or cannot be done in therapy. Jeitinho is an indigenous characteristic, generally described as an informal way of dealing with obstacles that makes rules and bureaucratic issues more flexible and employs charm and affections as a problem-solving strategy (Pilati et al. 2011). Jeitinho could be viewed as an adaptive strategy when it is used to describe a healthy relational way to seek flexible and creative solutions to some problems, but, on the other hand, it also could be maladaptive when inappropriate actions are used to overcome obstacles, becoming unacceptable (Miura et al. 2019). An example of how Jeitinho Brasileiro can impact the application of CBT is the fact that Brazilian therapists (in training) often believe that patients will not get used to the structure of CBT. A common example is the failure to use weekly action plans. Many therapists believe that the patient will not adhere to the plan and therefore do not use this important strategy. This attribution of meaning can be a cultural issue, associated with the aspects about the onset of clinical psychology in Brazil (Neufeld and Carvalho 2017; Neufeld et al. in press).

In view of these cultural and historical aspects, such as the influence of psychoanalysis and non-structured therapies in Latin America, the closer and the more passionate interpersonal relationships may not seem to match so well with CBT principles in a first look (Neufeld and Carvalho 2017). In other hand, as for specific aspects of each culture, Facio et al. (2017) emphasizes the clinical advantages of using more emotional metaphors and less rational debates with some Argentinian clients.

Regarding evidence presented by academic performance below the parameters proposed by the National Reform of Education (UNESCO-IBE 2010), Paraguayans appear to show more concrete thinking. This situation is mostly seen in Guarani speakers, as the Guarani language has a very peculiar structure and it is quite popular in Paraguay. On the positive side, according to Gallup (2018), Paraguay has been considered the happiest country in the world, for two consecutive years, with 85% of adults reporting their positive emotions experiences (Clifton 2012). Considering the cognitive aspects mentioned, CBT practice can be benefit due to a more behavioral and psychoeducation approach in the beginning of treatment. Concrete and practical strategies can work more effectively than Socratic and cognitive resources. Emotional education is another important variable to consider, including emotion expressions in Guarani. Consequently, if the therapist is used to a more cognitive style, this could be useful, because the patient could be able to respond better to techniques such as open questions and metaphors. However, it is better to do this after teaching the client how to identify and differentiate emotions.

Although more research is needed, these studies have already produced some interesting results, which strengthen the cultural differences of Latin America as a whole, as well as the existing differences between the countries of the region. Deepening knowledge on local and historical characteristics, strengthening research on cultural adaptation, and supporting educational material production and appropriate therapy application to the Latin American community (and their countries individually) are fundamental for the growth and dissemination of CBT in the region.

Challenges for CBT in Latin America

In Latin American countries, therapist training and clinical supervision are important challenges, because of the cost of training and the availability of trained supervisors. Likewise, although a sizable minority of psychiatry and psychology interns seek training in CBT, they have to pay for the training, which limits access. Mendoza (2017) also highlights the limited offer of specialized training in several countries in Latin America, most of them offering short courses, especially about third-generation models (i.e., acceptance and commitment therapy, dialectical behavior therapy, emotional activation, and mindfulness).

As an example, in Colombia, psychotherapist training in CBT is centralized at universities, and there is just one certified REBT non-university center, located in the city of Cali (Giusti 2009). New models, such as third-generation and post-rational approaches, have become more popular among Colombian and Chilean psychologists. These new models are sometimes criticized by more traditional therapists, but they have a good receptivity among professionals with academic interests and focused on people’s mental and emotional health. These initiatives have been incorporated in psychology programs at Colombian universities, with the only requisite of being evidence-based approaches.

In Uruguay, SUAMOC has played a very important role in the training of new therapists and has grown steadily since its foundation, having, nowadays, about 400 members. Currently, it offers the most accomplished postgraduate CBT training in the country. Another organization that offers this training is the Sociedad Uruguaya de Análisis y Terapia del Comportamiento. Alongside certifying psychologists and psychiatrists as CBT therapists, it offers further training in specific clinical topics (i.e., drug addiction) and in third-generation therapies (Lagos 2002). One of the main challenges for SUAMOC in Uruguay is the expansion and dissemination of CBT. It was not until 2013 that the Universidad de la República, the largest public university in the country, offered its first seminars on CBT.

As we focus on clinical supervision, other challenges arise. In Argentina, for instance, there is no formal training for supervisors, but some professionals have received these credentials abroad. Hence, the biggest challenge now is not disseminating the model, but ensuring the quality and fidelity of treatments. In Brazil, new therapists’ supervision is also considered a problem and a challenge. Developing supervisory skills is an important element for a good psychotherapeutic practice in Brazil (Barletta et al. in press). This exploratory research pointed out that supervisors’ training was perceived, by all participants, as the essential element to construct the meanings of task, role, skills, and responsibilities of a clinical supervisor.

On the other hand, results indicated the lack of elements considered important in CBT supervision, such as the use of direct clinical observations, the structures of supervision, and the focus on the development of clinical skills. Based on these results, a new training proposal was developed to increase supervisor’s reflection about the competency-based clinical process. Thus, it encouraged the incorporation of educational goals, different didactic methods, feedback training, and training and assessment of specific clinical skills (Barletta et al. in press). Currently, in Brazil, a national survey on the training process of supervisors is being conducted.

Research on CBT in Latin America

Scientific research in CBT has been growing throughout Latin America. Researchers have discussed the efforts to advance the dissemination and CBT implementation, with practice-oriented research and incorporating new technologies. In 2013, in Paraguay, for instance, the Master’s Degree in Psychology of the Catholic University of Nuestra Señora de la Asunción opened, being the first graduate program in the country to have an orientation in CBT. In Panama, a Doctorate in Clinical Psychology with a CBT emphasis was started and had formed the first class in 2008 (Manieri, 2014). Bethancout (2020) claims that 25% of the theses defended at the University of Panama are based on a CBT theoretical background.

In Brazil and Argentina, there are already numerous universities focused on CBT research. Moreover, in Brazil, there is a national association of Psychology research, with groups that integrate more than 50 PhD CBT researchers.

In Argentina, most CBT research programs are established at university labs and the national agency for scientific research (CONICET), and some programs are conducted at private CBT centers. Many of these projects involve cooperation with international research teams. Research programs have focused on anxiety disorders, eating disorders, obsessive-compulsive disorder, smoking cessation, perfectionism, adolescent mental health, borderline personality disorder, and non-epileptic seizures. This is an area in constant expansion in Argentina, despite the modest level of funding (Korman and Sarudiansky 2020).

In Brazil, there are already numerous CBT research groups in several public and private universities. Brazilian researchers have focused on a variety of research themes, for example, anxiety, depression, obsessive-compulsive disorder, eating disorders, substance abuse, and also social problems as violence, social and economic inequity, health promotion in school settings, and several other themes. Researchers have concentrated their efforts in studies on the CBT effectiveness in Brazil and in application of new technologies. Brief online interventions have been studied as alternative methods and have been shown to be effective for a variety of problems (Hester et al. 2012; Bedendo et al. 2018). Therefore, a study was organized in Brazil with the objective of evaluating the effectiveness of an online intervention to prevent alcohol abuse among university students, based on consumption feedback and psychoeducation. The outcomes demonstrated that the intervention carried out through web-based interventions can bring positive and promising results (Bedendo et al. 2020). The research of new kinds of psychological assistance associated with CBT is of great international relevance, showing that Latin American researchers can contribute to cutting-edge research topics.

In Paraguay, Benitez de Ortiz and Gamarra (2020) published a culturally adapted program to reduce anxiety in Guarani-speaking children, including components of emotional self-awareness and recognition of their emotions, cognitions, and behaviors. The results showed a moderate decrease in anxiety somatic symptoms and school phobia. Another research, based on a CBT-TF protocol, included with modified components of cognitive exposure to rejection and cognitive restructuring of reality. The research aim was to help sexual abuse victims cope with familial and cultural aspects derived from machismo (male chauvinism) (Figueredo and Gamarra 2018).

As in Brazil, a number of studies that have focused on the prevention of alcohol abuse increased in Uruguay. Alcohol represents the main drug consumed in this country, mainly among the young people. Researchers have investigated the quantity of consumption, the main consequences associated with consumption, and factors that stimulate it, such as psychological distress and starting age of consumption (Ruiz et al. 2020). This has contributed to building mechanisms for the prevention of abuse targeted at the young population. The outcomes favored the implementation of interventions by the team of experts in educational centers. These interventions aim to identify the main beliefs associated with higher levels of alcohol consumption in high school students and to offer educational and prevention workshops oriented to the dysfunctional beliefs that predispose young people to higher levels of consumption (Ruiz et al. 2019).

Notwithstanding the remarkable advances the scientific research area has promoted, CBT research in Latin America still faces considerable challenges. Political and economic issues directly interfere in these countries’ scientific development. Importantly, the development of a more robust CBT evidence base can grow through the collaboration between internationally dispersed researchers. Thus, there are numerous efforts by researchers from all countries, who continue to be concerned with an evidence-based CBT growth in Latin America.

Concluding Remarks

CBT has had remarkable growth all over the world, standing out as an evidence-based model and therapy. CBT integrates different strategies such as cognitive restructuring, problem-solving, and development of personal coping strategies, which has been easily adapted to different cultures. In Latin America, the CBT development was not different. And, because of significant cultural differences in terms of language, religion, customs, and moral values, the CBT dissemination has taken different paths in the diverse countries of Latin America.

Some challenges are common among several countries. Firstly, it would be commendable to create a national association of cognitive and behavioral therapies in some countries, to integrate every evidence-based intervention model, thus allowing professionals to be more inclusive in the academic training processes. Also, centers for the certification of future therapists in different cognitive behavioral models are needed. It is also necessary to expand research on specific demands of each community, as is the case with the current problem of the COVID-19 pandemic (OMS 2020) and the social distancing demanded to deal with it. The experience we are living with the coronavirus is teaching us the importance of assessing and considering psychological practice by online methods (De la Torre & Cebrián, 2018).

Therefore, the main challenge of the CBT in Latin America is to constantly reaffirm the scientific foundations of the theory and to continue to work in the production of scientific knowledge and its dissemination. Currently, many studies have been conducted on the CBT effectiveness in different countries in Latin America. In Uruguay, Brazil, and Argentina, for example, research about CBT in different contexts has been carried out, such as prevention of suicidal behaviors, intervention on children and teenagers, anxiety, depression disorders, and personality disorders. Another aspect that has been addressed recently in Latin America is the inclusion of cultural specificities of each country but at different times and ranges. Argentina, for example, already presents results of cultural adaptation research, while Brazil is starting this process. One of the difficulties encountered in creating this panorama of Latin America was the lack of studies and publications from several countries that make up this region. It is known that in some countries, the conditions for investment in scientific production are somewhat small, but in general, both practice and research in CBT are expanding throughout the region.

The training of new therapists has also been a focus of concern and investment in Latin American countries. The training of qualified professionals is very important for the approach to grow and successfully disseminate. In Brazil, for instance, the number of students in CBT-related undergraduate courses has increased, and applicants to postgraduate training courses have also grown in number. The importance of supervision has been emphasized in many countries, stimulating the qualification of therapists. The growth of research groups within universities has also been increasing in Latin American countries. The adaptation of CBT techniques not only in practice but also through scientific studies has consolidated CBT as an approach with positive and promising results for the Latin American community.

In view of the above, it is evident that the progress of recent years in relation to technical and research improvement will bring much progress to the practice of cognitive behavioral therapy in Latin America. Besides that, cultural adaptation of CBT might prove valuable for other cultures. Innovations in the implementation of therapy and in training might prove relevant for emerging countries, whose resources for training and research may be fairly different from those available in the more affluent countries in which CBT originated.