In April, the journal JAMA Psychiatry published a study that was reported to be the first of its kind. The randomized clinical trial used an insomnia treatment program for black women, adjusted elements such as visual content to make participants feel better, and discussed how black women's unique experiences contributed to their insomnia. Researchers found that culturally tailored programs were more effective than untailored treatment in engaging participants while still significantly improving their insomnia symptoms.
While this study is new, it touches on a long-discussed topic in the mental health field: how should therapists adapt their approach to accommodate people from different cultures, including racial and ethnic minority groups?
What is acculturation?
Psychological research has historically been biased toward the study of whites in Western societies, and practitioners should not assume that treatment and diagnostic tools designed for these populations will work for everyone. It is important to ensure that underserved communities are not excluded from effective services. "Cultural adaptation" refers to retaining the essential components of evidence-based tools while modifying aspects to increase the participation and relevance of the cultural groups served. A variety of factors must be considered, including language barriers, environment, race, ethnicity, country of origin, treatment goals, education level, and religious affiliation.
Does it work?
Evidence suggests that acculturation is effective. However, despite growing interest and awareness, the extent to which therapists practice acculturation with their patients remains unclear-and if they do, whether they do so effectively.
The field of mental health must make acculturation a focus of research and practice. Psychologists must build on previous work to understand how best to adapt therapeutic, screening, and diagnostic tools. They should also explore the barriers to applying these therapies in clinical settings. In addition, there is an urgent need for a standardized framework that allows for the routine and feasible application of culturally adapted interventions.
In the United States, the American Psychiatric Association's (APA) primary resource on the topic specifies some guidelines, but they are nearly 10 years old and lack references to standardized tools and methods for implementation, and it is unclear if and how these will be implemented. Putting it into practice. The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a resource used by mental health professionals to guide diagnosis, includes the Cultural Formulas Interview - questions professionals use to conduct cultural assessments related to diagnosis and treatment - and Experts believe it is not used as much and still needs improvement. Better guidance organizations such as the APA would help practitioners and organizations be better trained and able to adapt therapy to different cultures.
Some institutions have embraced a culturally sensitive approach to their work and research - and there should be more. Organizations such as UNICEF and the World Health Organization have recognized the relationship between culture and health. For example, UNICEF has developed cultural adaptation of screening tools to improve global measurement of adolescent mental health through the Measurement of Mental Health in Adolescents at the Population Level (MMAP) initiative, a project in which I have had the privilege of participating. Although mental health status is one of the leading causes of disability globally, there is limited data on mental health status in low- and middle-income countries and few instruments validated in these settings.
"If you don't understand cultural differences, you can completely misdiagnose patients," says Shervin Shahnavaz, a clinical psychologist and psychotherapist at the Karolinska Institutet's Center for Psychiatric Research and Center for Education and Research.
How should psychology fit in?
It is not always obvious when treatment or diagnostic tools need to be adjusted. Sometimes the need to adjust screening or treatment is obvious, for example, for internally displaced persons from the Boko Haram insurgency in Nigeria or refugees from unique, traumatic situations in humanitarian settings who may face language barriers and different cultural expressions and understanding of psychology and mental health.
Other times, the cultural differences may not be as pronounced. For example, the insomnia study looked at the U.S. population, but this treatment applies to black women because they have historically been underrepresented in the study, have a high prevalence of sleep problems and have previously proven less likely to initiate 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 reasons for the increased participation a major factor may be treatment experience. Because culturally adapted therapy uses materials featuring black women, it better reflects the study participants and may make the program more meaningful to them.
Iony Ezawa, an assistant professor in the Department of Psychology at the University of Southern California, says there may not be many adjustments to this approach - for example, cognitive behavioral therapy or CBT for insomnia research is a flexible option. Similarly, a validation approach - in which the therapist confirms that the patient's experience is understandable - may actually be the most effective treatment for certain groups. After all, the therapeutic relationship is one of the best predictors of treatment outcomes. But without further research and better guidance, clinicians may be left guessing about the best approach.
In addition, a study published in May explored whether a patient's race affects the way therapists deliver CBT - a common evidence-based treatment for depression. Ezawa and colleague Daniel Strunk, a professor of psychology at Ohio State University, reported that the therapists in the study found that the cognitive techniques typically employed in CBT were less appropriate when working with black patients compared to white patients. While validation can be considered a form of adaptation because it is culturally sensitive, it is unclear whether it is the most effective approach. As the authors of the study noted, "Whether such adaptation enhances or diminishes care for black patients is an important question worthy of future research." The field of psychology needs such research, and how best to apply acculturation therapy. Better guidance.
Until then, it is critical to adopt a patient-centered care practice. Therapists must continue to be aware of and respect cultural differences. Everyone, regardless of background, should have equal access to mental health care.
