4 In April, JAMA Psychiatry published a study that was reportedly the first of its kind. The randomized clinical trial used an insomnia treatment program for black women, adjusting elements such as visual content to make participants feel better and discussing how the unique experiences of black women contributed to their insomnia. The researchers found that culturally tailored programs were more effective than uncustomized treatments when it comes to attracting participants, while still significantly improving their insomnia symptoms.
While this study is new, it touches on a long-standing topic of discussion in the field of mental health: how should therapists adapt their approach to people of different cultures, including ethnic and minority groups?
What is cultural adaptation?
Psychological research has historically tended to study white people in Western societies, and practitioners should not assume that therapeutic and diagnostic tools designed for these populations are effective for all. It is important to ensure that underserved communities are not excluded from effective services. “Acculture” means retaining the basic components of evidence-based tools while modifying certain aspects to increase engagement and relevance of the cultural groups being served. Various factors must be considered, including language barriers, environment, race, ethnicity, country of origin, treatment goals, education level and religious beliefs.
Is it valid?
Evidence shows that acculturation is effective. However, despite the increasing interest and awareness of people, it remains unclear to what extent the therapists practice acculturation with their patients—if they did, whether they did it effectively.
The field of mental health must focus on cultural adaptation as a focus of research and practice. Psychologists must build on previous work to understand how best to adjust treatment, screening, and diagnostic tools. They should also explore barriers to applying these therapies in clinical settings. Furthermore, a standardized framework is urgently needed to enable routine and feasible application of culturally adapted interventions.
In the United States, the American Psychiatric Association (APA) major resources on the topic specify some guidelines, but they are nearly 10 years old and lack references to standardized tools and methods for implementation, and it is unclear whether and how to implement these. Put them into practice. The latest version of the Diagnostic and Statistical Manual of Mental Illness (DSM-5) is a resource used by mental health professionals to guide diagnosis, including cultural formula interviews—problems that professionals use to conduct cultural assessments related to diagnosis and treatment—experts believe that not so much is used and still needs improvement. Better coaching organizations such as APA will help practitioners and organizations get better training and be able to adapt therapies to different cultures.
Some institutions have accepted the work and research in a culturally sensitive way—and there should be more. Organizations such as UNICEF and World Health Organization have recognized the relationship between culture and health. For example, UNICEF has developed a cultural adaptation of screening tools to improve global measurement of adolescent mental health through the Population Level Adolescent Mental Health Measurement (MMAP) initiative, a project I have had the honor of being involved in. Although mental health status is one of the leading causes of disability globally, data on mental health status in low- and middle-income countries are limited and tools are rarely validated in these settings.
“If you don’t understand cultural differences, you may completely misdiagnose patients,” said Shervin Shahnavaz, a clinical psychologist and psychotherapist at the Center for Psychiatry Research and Education and Research at the Karolinska College.
How should psychology adapt? When
needs to be adjusted for treatment or diagnostic tools is not always obvious. Sometimes the need to adjust screening or treatment is evident, for example, for internally displaced persons from the Boko Haram rebellion in Nigeria or refugees from unique, traumatic situations in the humanitarian environment, who may face language barriers and diverse cultural expressions and understanding of psychology and mental health.
Other times, cultural differences may not be so obvious.For example, the insomnia study looks at the U.S. population, but this treatment is suitable for Black women because they have historically been underrepresented in the study, have a high incidence of sleep problems, and have previously proven unlikely to start and continue treatment, according to Eric Zhou, lead author of the study and assistant professor of pediatrics at Harvard Medical School, while the study did not examine the exact cause of increased participation, a major factor may be treatment experience. Because the adaptive therapy uses materials characterized by black women, it better reflects the research participants and may make the program more meaningful to them.
The approach may not have much tweaked—for example, cognitive behavioral therapy or CBT for insomnia studies is a flexible option. Similarly, a validation method—the therapist confirms that the patient’s experience is understandable—is actually the most effective treatment for some groups. After all, treatment relationships are one of the best predictors of treatment outcomes. But without further research and better guidance, clinicians may guess the best approach.
Additionally, a study published in May explored whether a patient’s race affects the way therapists provide CBT—a common evidence-based treatment for depression. Ezawa and colleague Daniel Strunk, professor of psychology at at Ohio State University, reported that therapists in the study found that cognitive techniques commonly used in CBT were less appropriate when working with black patients than white patients. While verification can be considered a form of adaptation because of its cultural sensitivity, it is not clear whether it is the most effective method. As the authors of the study noted, “whether this adaptation enhances or weakens care for black patients is an important question worthy of future research.” The field of psychology requires such research, and how best to apply adaptive therapies. Better guidance.
Before this, adopting patient-centered nursing practices was crucial. Therapists must continue to be aware of and respect cultural differences. Everyone, regardless of background, should have equal access to mental health care.
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