A suite of culturally adapted cognitive behavioural therapy tools is designed to break through barriers.

It was hard to hear clearly at first, but once they figured out the practicalities of a virtual therapy session in which the client was calling her from her closet, things started to go smoothly.

“In my past roles, a call from a closet would not have been a session — we would have asked that the client cancel it,” explains Helen Yohannes, a registered psychotherapist at the Somerset West Community Health Centre in Ottawa, and one of 29 practitioners in a research project to test a new form of psychotherapy for South Asians in Canada who are affected by anxiety and depression.

“There might be a client who is hiding their therapy from their family,” Yohannes says. “In this study, we accommodate for things like that. We are looking to the client’s needs, rather than what we think is an effective process.”

This was one takeaway from the study Development and Evaluation of Culturally Adapted CBT to Improve Community Mental Health Services for Canadians of South Asian Origin, produced by the Centre for Addiction and Mental Health (CAMH), the Mental Health Commission of Canada (MHCC), with site partners Moving Forward Family Services (Vancouver), the Ottawa Newcomer Health Centre, and Punjabi Community Health Services (Toronto). From the research, a suite of culturally adapted cognitive behavioural therapy (CBT) tools was developed for use with clients from these communities.

What is cultural competence?
Adding cultural awareness can make CBT — known informally as the “gold standard” of therapy — more inclusive to non-Western communities and improve its acceptability and impact. “Regular” CBT tends to focus on a person’s day-to-day problems and help them interpret and evaluate what’s happening around them. Culturally adapted CBT does this too but with subtle, effective adjustments.

Cultural competence is broadly defined as the ability of providers and organizations to effectively deliver health-care services that meet the social, cultural, and linguistic needs of patients. In practice, it translates in various ways.

For example, clients in the study expressed a desire for the therapist to build rapport and to burnish the clinical feel for a warmer dialogue with a bit of personal disclosure — something that may have an out-of-guidelines feel for some practitioners.

“People who are socially skilled or emotionally intelligent tend to do these things in a very smart way,” says Dr. Farooq Naeem, a professor of psychiatry at the University of Toronto and CAMH clinical scientist who was the principal investigator for the study. Naeem also co-developed the Southampton Adaptation Framework, based on a 2006-2009 study in Pakistan that informed the new research.

At the start of our interview, we exchange notes on our cultural backgrounds, and he cites this mutual disclosure – a friendly where-are-your-fromming – as the kind of door opening that helps with cultural adaptations to CBT.

“It is a way of trusting – before getting right into the personal information,” he says.

Additional tips and tools also encourage practitioners to engage the client’s extended family in a collectivist approach to therapy and treatment.

Feedback from study participants has also helped to shape practitioners’ approaches to treatment. For example, some clients felt they were instructed to go against their beliefs and values for favourable results in therapy. In one case, a counsellor telling a client to draw hard boundaries with their parents was seen as overly simplistic when family dynamics were not aligned with such an approach.

Also important is understanding how spiritual practices fit within a client’s perspective.

“The individual may have their own idea as to what is causing their challenges, which could be rooted in religious or spiritual beliefs,” says Kamlesh Tello, a program manager at the MHCC, focused on access to quality mental health services, and part of the project team.

“Circumstances that have come about could be attributed to God’s will, karma, or an evil eye, for example. It’s important for the provider to know how to navigate that with the client.”

Practitioners are advised to have discussions with the client about their perspective, without disagreeing or suggesting other explanations, to help form connections with the client’s thoughts and feelings.

However, in other scenarios, care providers are advised to use more directive methods in therapy sessions, which can seem like conflicting guidance. Naeem bridges the disconnect.

“Many non-Western cultures are still very hierarchical in their style of communication, which is sermon-style compared with a Socratic dialogue — open, guided, curious — which is CBT-style,” he says. “They will doubt your judgment if you ask them about a therapeutic approach.”

This does not apply across the board, once you factor in acculturation — how Westernized one is in this context. Naeem advises against generalizing. Rather, providers can take a self-reflective approach that allows them to confront their conscious and unconscious biases while working with South Asian clients.

Structural stigma
Even with awareness efforts, clients in the study acknowledged the wider systemic challenges of racism, discrimination, immigration and settlement, and other socio-political factors beyond their control that affected their identity, societal role, and mental health. As a caregiver from the Greater Toronto Area noted, “There is bias in therapies, bias in systems, and bias in people who control these systems. They’re not aware of it, or even if they are, they’re in denial of these biases wrapped within these systems. And these biases will definitely impact the way therapies are delivered to people who are marginalized, people who are disadvantaged, and people who belong to equity-seeking groups.”

Such biases discourage the use of mental health services, as research shows these communities are less likely to access help than are other people in Canada. About seven per cent of Canada’s population (2.6 million people) identify as South Asian, making it the country’s fastest-growing racialized group.

Beyond words
The suite of self-paced training videos and guides on culturally adapted approaches to CBT for South Asian communities can help practitioners from any cultural background, Yohannes says.

“I thought, ‘I’m not South Asian, I am East African from Eritrea — I probably have some cultural similarities’ — but I was also hesitant. What if clients did not want to see me?” Thankfully, those thoughts were quickly debunked.

“The people in the study just wanted someone who was competent to provide therapy and be open to cultural aspects that could change the way we implement therapy, or even how we have our sessions,” she says (citing the client-in-the closet scenario), as well as changing norms within the profession.

“You see a lot of cultures where there is a hesitancy to talk about what goes on at home with strangers. There can be a sense that the client is not ready to open up, and then they are sent away and told to come back when they are ready to talk. I have seen that with therapists who may not be as culturally aware. It is something to work through.”

Yohannes says that therapists must be willing to learn and be open to conversations about racism. “You can’t escape that topic. You have to have the ability to talk about microaggressions or anxiety and depression and how it relates to race.”

This was confirmed by study participants who felt that therapists who had received culturally adapted CBT training could relate to the client’s circumstances. “I didn’t have to spend time informing, training, or educating the [therapist] about my culture or realities of being historically and culturally persecuted,” a participant said.

This understanding helped with retention and completion rates for therapeutic sessions with the study’s 146 participants — half of whom received culturally adapted CBT (versus half with standard CBT). Their countries of birth included Canada, Afghanistan, Bangladesh, India, Nepal, Pakistan, Sri Lanka, England, the United States, Qatar, the United Arab Emirates, the United Kingdom, and Sweden. Religious or spiritual affiliations included Hinduism, Islam, Sikhism, Buddhism, Christianity, Zoroastrianism, atheism, and agnosticism.

“Multicultural and cultural — we use these words a lot, but I don’t know that we unpack them as much,” Yohannes says, when talking about the term “culturally aware.” She says that practitioners cannot apply one type of therapy to every group and assume it’s going to work, as such rigidity and generalization goes against the spirit of the work. Rather, it’s about an openness to new approaches and a willingness to shift them.

“That’s when you see people more willing to talk about mental health.”