Strategies of psychotherapies that improve self-concept

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Theoretical Background

Minority status

Minority status has an effect on human beings. It can be defined as a feature of a group’s cultural and psychological experience (Potts & Watts, 2003). Minority status is usually interrelated with socioeconomic status, the experience of migration and discrimination (Bernal, Trimble & Burlew, 2003). Although there are variations between people with minority status, there are two similarities (Potts & Watts, 2003). These similarities are the experience of oppression and the experience that they need to adjust themselves to the dominating culture (Potts & Watts, 2003). Minority children are a growing part of the population (McLoyd, 1990). In the formation of identity, children and adolescents of a minority group may face more challenges due to physical characteristics, behavioral distinctions, language differences and social stereotypes (Spencer & Markstrom-Adams, 1990). In this study, the minority children that are examined are children from an ethnic minority, immigrant children and refugee children

Children from an ethnic minority

Children from an ethnic minority could be viewed as children with a minority status. An ethnic group can be defined as a group of people that share a common history and culture, and may have similar physical features and values (Smith, 1991). Race and ethnicity can be used to define one’s power, due to a lower number of people of this group in the society. This can be defined as an ethnic minority (Smith, 1991). Ethnic inequalities in child health and wellbeing has been studied in diverse countries and reveals growing evidence that racial discrimination affects children and youth’s well-being. Among these studies are African-American, Asian, and Latino populations (Priest et al., 2013). Some studies have also shown that African-American children have significant lower self-concepts (Kenny & McEachern, 2009). However, research has been inconsistent about the effects of ethnicity on self-concept (Brown, 1998)

 Immigrant children

Immigrant children could also be viewed as children with a minority status. An immigrant can be defined as a person who has chosen to move across international borders to improve his life (UNHCR, 2016). Research has shown that immigrant children had the lowest levels of psychological well-being, moods and emotions, peer relations and social acceptance (Hjern et al., 2013). Another study revealed that immigrant children have significantly less self-esteem and higher depression and anxiety compared to non-immigrant children (Diler, Avci, & Seydaoglu, 2003)

Refugee childre

Refugee children can be seen as children with a minority status. It can be defined as a child that is fleeing armed conflict or persecution (UNHCR, 2016). According to the UN refugee Agency (2017) there are currently 21,3 million refugees and over half are under the age of 18 years old. Refugee children are at increased risk of a wide range of psychological problems (Ugurlu, Akca, & Acarturk, 2016). Refugee children show a high prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), aggression and behavior problems (Ugurlu et al., 2016). Other reported problems such as somatic complaints, sleep problems, conduct disorder, social withdrawal, attention problems, generalized fear, overdependence, restlessness, irritability and difficulties in peer relationships (Ehntholt & Yule, 2006). Also, in very young children regressive behavior, such as loss of bladder control, separation anxiety can be common. Moreover, adolescents might be at increased risk of developing psychosis (Ehntholt & Yule, 2006).

Children’s rights

The Convention of the Rights of the Child (United Nations General Assembly, 1989) states in Article 24 that the child has the right of the highest attainable standard of health and facilities of treatment of illness and rehabilitation of health. Additionally, Article 27 declares that State Parties should also recognize that every child has the right to a standard of living adequate for the child’s physical, mental, spiritual, moral and social development. Refugee children are specifically addressed in the Convention in Article 22 where it is stated that State Parties are responsible for the appropriate measures to ensure protection and humanitarian assistance for refugee children to enjoy the rights of the Convention. According to the Convention a child is defined as every human beneath the age of 18 years old. Refugee children below the age of 18 therefore have the right for treatment for the wide range of psychological problems

Self-concept
What is self-concept

Self-concept refers to a multidimensional concept of neurophysiologic components and psychological components (Simons et al., 2012). It can be defined as the totality of perceptions that each person has of himself (Simons et al.,2012). Some researchers categorize self-concept into divisions such as the social-, affect-, competence-, physical-, academic- and family self-concept (Bracken & Lamprecht, 2003). Other divisions are the private-, public-, relational- and collective self-concept. However, no model has been advanced to take in all diversity of the self-concept (McConnell, 2011).
McConnell (2011) explains that the self-concept can involve identities (e.g. religion), roles (e.g. family member roles, profession), social relationships, goals (e.g. ideals, fears), affective states (e.g. being a moody person), and behavioral situations (e.g. the kind of person that does charity) . McConnell implies that a self-concept is temporal, so it can be about a past-, present-or future selves (McConnell, 2011). Divisions of self-concept vary tremendously in the literature based on the perspective taken (McConnell, 2011). Additionally, a distinction can also be made between self-concept (what one thinks about oneself) and self-esteem (how one feels about oneself). However, some researchers use these terms interchangeably (Simons et.al.,2012). For this systematic literature review, self-concept refers to the totality of the aspects that are described by the term self-concept, and not to a specific subcategory.

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The development of self-concept

The development of a child’s self-concept is shaped by both cultural and biological factors and formed by the individual through interactions with the environment (Kenny & McEachern, 2009). How the self-concept is structured and organized varies across cultures (Kirmayer, 2007). The content of the self-concept (how to behave, feel etc.) is formed by cultural knowledge (e.g. roles or stereotypes), feedback from others and our own inferences of our behavior and feelings (McConnell, 2011).
The development of self-concept starts early on. Brown (1998) suggests that newborns enter the world with the ability of self-awareness, which is the basis. Social interaction and language are the other keystones necessary to complete development of the self-concept (Brown, 1998). Self-concept becomes more multi-faceted with age (Bracken, 1995). This means that self-concept consists of more aspects the older someone gets.
Gender and age appear to be the first characteristics at age 2, followed by concrete, observable characteristics (physical appearance, typical behaviors and activities) (Brown, 1998). Brown (1998) states that during middle childhood (age 7-11) children start using social traits (e.g. friendly) and broader labels ( e.g. I like sports). He suggests that changes in self-concept are due to changes in cognitive maturity. In middle childhood children learn the ability to see themselves from another’s perspective, making social comparison possible (Brown, 1998). Around this age self-esteem evolves (Bracken, 1995).Finally,adolescence brings another shift in descriptions: they use abstract qualities that emphasize their perceived inner emotions and psychological characteristics (e.g. insecure or moody) (Brown, 1998).
Brown (1998) explains that self-development is more rapid in childhood but people’s ideas about themselves change throughout life. Some people have a rich variety of selves, while others are more stable in different contexts (McConnell, 2011). Some researchers also stress the importance of cultural differences on self-concept (Berry, Poortinga, Segall, & Dasen, 2002; Kenny & McEachern, 2009; Kirmayer, 2007; McConnell, 2011). For instance, in some cultures self-concept is described with social interactions and not with personality traits (McConnell, 2011)

What affects the self-concept

According to McConnell’s (2011) there are factors that interplay with self-concept. Depending on the stimuli of the context, a self-concept linked to a role is provoked (McConnell, 2011). For example, when a child sits in a classroom, his self-concept of the student is provoked. Every self-concept contains typical attributes, such as affects, traits, behaviors, physical characteristics or social categories (McConnell, 2011). These typical attributes are used in that context. Furthermore, bodily reactions and the person’s evaluation of themselves affect self-concept (McConnell, 2011). The bodily reaction can affect evaluation (McConnell, 2011). For example, a child might evaluate himself more positively when he feels happy. But evaluation can also affect bodily state (McConnell, 2011). For example, if a child is social and judges this as good behavior, he could feel happier.

The effects of self-concept

The effects of self-concept are versatile. Self-concept plays an important role in psychological functioning for everyone and appears to be a significant predictor of mental health (Simons et al.,2012). Generally, self-concept fulfills a need in humans by creating predictability (James & Foster, 2003; Kirmayer, 2007). There is some evidence that implies that a lot of differentiation in self-concept leads to psychological problems (Styla, 2012). A positive self-concept, however, is strongly related to resilience (Rutter, 2000). The definition of resilience is the ability to achieve a positive outcome despite challenging or threatening influences. Moreover, resilience indicates the possession of skills that help an individual cope with challenges (Zolkoski & Bullock, 2012). People that have resilience, have been able to lead more successful lives than expected, despite being at greater risk for a negative outcome (Zolkoski & Bullock, 2012).
Self-reports on resilience emphasize the importance of their own positive self-concept and their attitude toward and conceptualization of their negative experiences (Rutter, 2000). A positive self-concept might make people less vulnerable to emotional pain, threat confidence or social rebuffs (Rutter, 2000). Moreover, people with positive self-views tend to be happier, have a better subjective sense of well-being and profess greater life satisfaction (Bracken & Lamprecht, 2003).

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 How to improve self-concept

Brown (1998) states that overall people actively search for new knowledge about themselves and generally maintain positive self-concepts by searching for positive feedback. Some people, however, have a negative self-concept and seek negative information to confirm this evaluation (Brown, 1998). Many theories suggest that psychotherapy could lead to changes in self-concept (Styla, 2012).

 Psychotherapy
What is psychotherapy

Psychotherapy is the act of helping a person to relieve psychological distress or disability by psychological means. The difference with informal help, like a friend to talk to, is that psychotherapists are specially trained to conduct this activity and they are systematically guided by an articulated theory that explains the sources of the patients’ distress or disability and prescribes methods to alleviate them (Bloch, 2006). Psychotherapies use explicit talk about the person’s thoughts, emotions, feelings and relationships (Kirmayer, 2007).
Truscott (2010) states that research comprises consistent support that psychotherapy is highly effective. Furthermore, research also proves that there is no significant difference of effectiveness of any type of psychotherapy (Truscott, 2010). Major modalities in psychotherapy are psychodynamic therapy, cognitive and behavioral therapy, interpersonal psychotherapy, group psychotherapy, cognitive-behavioral group interventions, family therapy, psychodynamic couple therapy, cognitive behavioral therapy with couples and the art therapies (Gabbard, Beck, & Holmes, 2005).
Truscott (2010) claims that an effective treatment should involve three components: activities consistent with a therapeutic rationale, activities which the client believes to be helpful and a collaborative relationship. Although no theory of psychotherapy is superior to another, a theory can be used as a map of the psychotherapeutic territory and it leads to hypothesis, tasks, goals and evaluation (Truscott, 2010). Children have not acquired the abilities to verbally describe and reason their feelings, thoughts and behaviors (Hall, Schaefer, Kaduson, 2002). Therefore, other methods are needed to help children express their emotions and thoughts (Ugurlu et al., 2016)

Cultural adaptation in psychotherapy

Cultural adaptation was implemented in psychotherapy after numerous concerns in research with participants from diverse cultures (Bernal & Rodríguez, 2012). It refers to systematic changes made in the treatment so that features of culture and language are part of the treatment (Bernal & Rodríguez, 2012).
Kirmayer (2007) claims that if the self-concept varies, then the goals and method of the psychotherapy must also differ. For example, in one culture holding back one’s personal experience would be attributed to somatic and emotional illness. The method is training in self-expression and assertion. Therapy goals are self-control, self-efficacy, self-expression and confidence. In contrast another culture may consider the expression of emotion as potentially harmful for the person, the family and society and the person should strive for acceptance and harmony instead of domination and control. Dependency is a positive expression of relatedness and acknowledgement of others (Kirmayer, 2007).
Kirmayer (2007) states that effective therapy must therefore appeal to personal values of the cultural background and should articulate the tension between traditional values and new choices brought by social change or migration. Additionally, by construing the self-concept in therapy sessions, the therapist should be aware of the clients’ personal norms and values and the consequences on personal, familial and community level (Kirmayer, 2007).

Rationale

Living with a minority status as a child is interrelated with diverse mental health problems. Minority children are a growing part of the population and some studies reveal higher prevalence of mental health problems with refugee children, immigrant children and children of a different race or ethnicity. Studies show higher prevalence of depression and anxiety and lower self-concept or less self-esteem. Positive self-concept has been correlated to resilience and mental health. As resilience is the ability to achieve a positive outcome despite challenging or threatening influences, children with minority status could benefit from resilience given the increased risk for mental health problems. Self-concept can be altered by psychotherapy. Because the culture has an influence on the formation of self-concept and the therapeutic goals and method of treatment, psychotherapies should be evaluated with children or adolescents with a minority status.
The purpose of this study is to find psychotherapies, conducted among samples of participants with a minority status, that improve self-concept so that a positive self-concept can be stimulated in children and adolescents who are in need of more resilience due to mental health problems

1 Introduction 
2 Theoretical Background 
2.1 Minority status
2.2 Children’s rights
2.3 Self-concept
2.4 Psychotherapy
2.5 Rationale
2.6 Aim
3 Method
3.1 Design
3.2 Search strategy
3.3 Selection process
3.4 Data extraction
3.5 Quality of the studies
3.6 Data analysis
3.7 Ethical consideration
4 Results 
4.1 Strategies of psychotherapies that improve self-concept
4.2 In what way do psychotherapies improve self-concept
5 Discussion
5.1 Discussion of results
5.2 Discussion of methodology
5.3 Limitations
5.4 Future research and clinical implications
6 Conclusion 
References 
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