Integrating culture and religion/spirituality with evidence-based treatments for underserved groups
Applied Impact Statement: This article provides information that clinicians and researchers may find beneficial when trying to develop and provide access to evidence-based treatments for underserved groups. We review culturally informed therapy (CIT) and its efficacy, share lessons we learned when delivering CIT in Spanish, and our approach to delivering CIT among Muslims.
Individuals from minoritized backgrounds often lack access to adequate evidence-based care. Many are reluctant to seek professional psychological help (Cook et al., 2017), and those who do are more likely to drop out of treatment prematurely (Mowbray et al., 2018). The underutilization of mental health treatment is in part due to higher stigma of mental health among racial/ethnic minorities (Wong et al., 2018), concerns that therapy may not align with diverse cultural and/or religious/spiritual beliefs and values (Khan et al., 2014), as well as negative beliefs about psychological treatment, such that it is secular and created by White providers for White clients. Culture and religion/spirituality play important roles in an individual’s conceptualization and experience of mental health difficulties and how to overcome them. For example, the DSM-5 (APA, 2013, p. 758) has clarified its stance on cultural syndromes, and now states that “all forms of distress are locally shaped.” In order to increase openness to and the effectiveness of psychotherapy for individuals of all backgrounds, evidence-based treatments should incorporate salient aspects of clients’ cultural identities. This was supported by a meta-analysis showing that interventions with cultural adaptations (relative to unadapted versions of the same interventions) resulted in significantly greater reductions in psychopathology (Hall et al., 2016).
One way to address disparities in mental health care is to create greater access for individuals from minoritized backgrounds to receive training as providers. First, therapists from minoritized backgrounds offer a needed perspective in the development and provision of therapeutic intervention. In addition, some clients have a demographic preference, and when this preference is honored, dropout is lessened (Swift et al., 2018). However, it is not always feasible to match clients with therapists according to cultural, racial/ethnic, gender, and religious/spiritual demographics, especially as clients and therapists have multiple intersecting identities (Ertl et el., 2019). Likewise, although education in cultural diversity is paramount, therapists (even of matching demographics) cannot be expected to be experts in each of their potential clients’ backgrounds, nor does matching predict higher quality intervention (Cabra et al., 2011). While matching may be clinically indicated in some cases, culturally informed care should ideally reduce the need for matching so that providers can adapt their therapeutic process appropriately to each client.
Identifying cultural contexts of behaviors and coping during assessment and therapy is likely to enhance our understanding of those we serve and how to provide them appropriate care (Forehand & Kotchick, 1996). Conversely, when clients feel seen and heard, they may also feel more comfortable engaging in shared decision-making (e.g., collaborative empiricism; Clark, 2013) regarding their difficulties and how to address them in ways that do not infringe upon their beliefs, values, and right to self-determination in mental health care. Culturally informed care may increase the likelihood that those who need mental health care will seek it out and see it through. However, the process of developing and disseminating evidence-based treatments for underserved groups can be challenging, and below we discuss some of our own struggles.
In this article, we will review Culturally Informed Therapy (CIT), a treatment that seeks to bridge the divide between underserved cultural and religious/spiritual groups and evidence-based treatments. CIT has been translated and offered in Spanish, for which we received the 2019 Gelso Award, and is currently being adapted for Muslims, for which we received the 2022 Gelso Award. We provide findings from this line of work, report on lessons we learned in the recruitment and retention of clients while providing Spanish CIT, and discuss adaptations that were made to serve Muslims, a particularly at-risk and underserved religious group.
Culturally Informed Therapy (CIT)
Culturally Informed Therapy (CIT) was developed by Dr. Amy Weisman de Mamani at the University of Miami. It combines modules from established cognitive-behavioral therapies (Psychoeducation, Communication, and Problem Solving) with modules that focus on cultural (Collectivism) and religious/spiritual (Spirituality) identities and coping. CIT has been offered in single-family format for individuals with schizophrenia and their families (called CIT-S), and in group format at academic and religious institutions, with separate groups for individuals with general mental health concerns (anxiety, family conflict, grief), and serious mental illnesses (schizophrenia, bipolar disorder). In 2020, groups moved online during the COVID-19 pandemic and have remained virtual.
Starting with the assessment and throughout treatment, clients are asked about how their cultural and spiritual identities act as sources of strength and contribute to difficulties with their relationships, mental health, communication, and problem solving. Using handouts and open-ended questions, therapists attempt to capture nuances within clients’ identities (e.g., the intersection of acculturation and intergenerational differences). This process improves therapists’ understanding of their clients, connects presenting concerns to cultural contexts within which they occur, and guides topics covered in treatment. Therapists help clients understand how cultural and religious/spiritual beliefs and practices can serve as both risk and protective factors, and encourage future practices that contribute to better mental health and overall well-being. Sessions begin and end with prayers, readings, or meditations. Clients are provided home learning tasks at the end of each session, and discuss results at the start of each following session.
Brief Description of CIT
The first module of CIT is Collectivism, which seeks to understand and develop clients’ social support networks (such as with family, friends, and faith communities) and their roles within them. Topics such as family conflict, sharing responsibilities, and maintaining meaningful relationships with others are often covered. Collectivism is followed by Psychoeducation, in which therapists explore how clients understand mental health difficulties through their culture (e.g., mental health stigma and cultural syndromes). Therapists share conceptualizations of those difficulties from the scientific and clinical literature, and highlight that different explanations co-exist and often intersect. Clients are encouraged to practice coping strategies that utilize the benefits of both methods. Psychoeducation is followed by Spirituality, which explores clients’ religious/spiritual values, coping strategies, and difficulties. Clients share prayers, readings, and symbols that are meaningful to them. Where appropriate, therapists encourage adaptive coping practices and discourage maladaptive coping practices. Adaptive religious/spiritual coping practices include forgiveness, volunteerism, and addressing difficulties alongside praying. Maladaptive practices include appraisals of difficulties as punishments from God, and using spiritual beliefs and practices to avoid addressing one’s difficulties (i.e., spiritual bypass).
The fourth module of CIT is Communication, which explores clients’ cultural forms of communication and involves role-playing methods such as active listening, making requests for change, and expressing negative feelings. Therapists and other group members provide feedback, and clients are asked to practice skills outside of group. If the recipients of clients’ communications are not responsive, clients are directed to the final module, Problem Solving. Problem Solving explores clients’ cultural methods of addressing difficulties, and shares the step-by-step approach to problem-solving that lists possible solutions (therapists and group members brainstorm ideas collectively), analyzes their pros and cons, and chooses a solution (or solutions) that best fits each context. Clients practice solutions on their own, and discuss results with the group. A more detailed description of CIT, along with handouts and case examples, can be found in Weisman de Mamani et al. (2021), though this version of the intervention was geared toward treating people with schizophrenia and their family members.
Efficacy of CIT
CIT has shown efficacy in improving both mental health symptoms and general well-being. In a pilot study conducted among people with schizophrenia, CIT-S was more effective than a psychoeducation-only comparison condition in reducing psychiatric symptoms (Weisman de Mamani et al., 2014). In a study of caregivers of individuals with schizophrenia who went through CIT-S, Weisman de Mamani and Suro (2016) found that the intervention outperformed a psychoeducation-only condition in reducing caregiver burden as well as guilt/shame. Maura and Weisman de Mamani (2018) also found that CIT-S administered in a multifamily group format was similarly effective in reducing psychiatric symptoms. Furthermore, the intervention has demonstrated superiority to a psychoeducation-only comparison condition in reducing depression, anxiety, and stress in both people with schizophrenia and their caregivers (Brown & Weisman de Mamani, 2018). In this same study, it was found that CIT-S increased family cohesion, and this change mediated the treatment effect on clients’ symptoms.
Since these earlier studies on the family which focused on CIT-S, the treatment has been expanded to assess its utility among various other groups and settings to determine its generalizability across contexts. In a collaboration with the Coral Gables United Church of Christ (UCC), we delivered CIT in group format to community members. Group members could join at any point and remain in CIT until their needs were met. Participants reported significantly improved quality of life and greater usage of religious/spiritual coping strategies, with qualitative responses suggesting that they held their experiences in high regard (Weisman de Mamani et al., in press). Weekly assessments also demonstrated reductions in psychopathology with number of sessions attended (McLaughlin et al., in preparation).
Notably, Pastor Laurie of the UCC reminded congregants about our services each Sunday, and the church newsletters and social media pages frequently shared our flyer. Over the last three years, we have had a consistent turnout in three groups (one serious mental illness group and two general mental health groups). We limited group sizes to 8 members after our transition to virtual sessions due to our observation that this was the most we could manage per group while giving adequate attention to each client. Our collaboration will end in May 2023.
Lessons learned through Spanish CIT
After making culturally relevant adaptations to our materials, and translating and back translating all of our questionnaires and handouts to Spanish, we began advertising Spanish CIT in local newspapers, public transport, churches, and some private practices. Although the initial response was positive (we assessed multiple clients who were then waitlisted), it took a few weeks for us to gather enough clients to begin our first group. As most individuals in Miami are bilingual Spanish-English speakers, a few waitlisted clients asked to receive CIT in English to begin treatment right away, and were transferred. Unfortunately, when we had enough clients to begin, we were unable to recontact many on our waitlist. This left our client pool much smaller than expected, as we had high numbers of Spanish-speaking participants for our prior in-person group studies, and before COVID-19, we had many inquiries and a fairly deep waiting list for this intervention. Some on our waitlist also described facing technological difficulties, and while this warrants deeper inquiry, it may be that cultural factors such as personalismo (i.e., the emphasis placed on interconnectedness) had pushed previously interested members away from virtual/online therapy.
Importantly, many clients were managing difficulties that disproportionately affected minoritized groups during COVID-19, such as the virus and other health concerns, the passing away of loved ones, job losses, and financial hardships. South Florida also became the worst housing market nationwide (Randall, 2021), and this particularly impacted the Spanish-speaking majority, many of whom worked labor intensive jobs. As a result, we were only able to launch and sustain one group, in which attendance was variable, with many clients unable to prioritize therapy despite recognizing the need for help when they would attend. A monolingual client left Spanish CIT after completing one round of treatment due to a health crisis, and we helped them establish a care team due to their language barrier. The low group size and low attendance also resulted in one client expressing their preference to join CIT in English to attend a group with consistently larger numbers. After two rounds of Spanish CIT, the group was ultimately terminated, and clients were either discharged or transferred to English CIT.
At the same time, those who completed Spanish CIT reported very positive feedback on qualitative surveys that asked them what they liked about the treatment and what they would improve upon. Some representative comments (all translated from Spanish) include: “They gave me excellent ideas about how to move forward; they helped me to believe that I am a good person,” and, “They helped me understand my relationship with God.” Two themes emerged for improving therapy. One member said that it would be nice to have a larger group (presumably as an opportunity to meet more people and hear more diverse ideas). Another said that they would like to receive the therapy videos for review. However, we were unable to provide these for ethical concerns around violating the privacy of other group members. During informal communications, one client mentioned that they had referred family and friends to us, and another recognized the large gap in treatment for Spanish-speaking populations and commended our work.
We learned a few valuable lessons from this experience. First, the importance of a community’s involvement in their own care cannot be overstated. Pastor Laurie’s enthusiastic endorsement of CIT was monumental in providing a steady stream of clients, many of whom reported needing multiple invitations before they felt ready to call us. We also learned that high mental health stigma in the Hispanic community was a barrier for many who shared concerns about privacy, small group sizes, and teletherapy. Relatedly, we realized that due to the virtual format we could expand recruitment beyond Miami (clients just needed to be present in Florida). Thus, we implemented these lessons when we developed the next leg of CIT, adapted for Muslims.
CIT for Muslims (CIT-M)
Muslims living in the United States (MLUS) are an at-risk group due to the high rates of discrimination they face and a low likelihood of seeking psychological help in addressing mental health concerns. Prior to initiating CIT-M, we conducted research on MLUS to determine adaptations to our treatment. We investigated Muslim mental health stigma, help-seeking attitudes, and treatment preferences (e.g., matching therapist demographics, comfort with having other Muslims from their community in their therapy group; McLaughlin et al., 2022a). Other research topics included Islamophobia/discrimination, challenges faced by converts (McLaughlin et al., 2022b), different experiences between immigrant vs. US-born Muslims (Ahmad et al., under review), and the effects of spiritual bypass on Muslim religious/spiritual coping, mental health, and stigma/help-seeking (Ahmad et al., 2022a; Ahmad et al., 2022b). We used findings from our own work and the work of other scholars to make adaptations to our handouts to ensure we touched upon key areas that were relevant to Muslim mental health.
To overcome the challenges we faced during Spanish CIT, we recruited Muslim post-baccalaureate and graduate students from across Florida who are passionate about serving their communities. These research coordinators are conducting outreach, disseminating flyers, and answering questions on our behalf. We have also connected with various imams to provide input and help us recruit clients from beyond our borders, and with Muslim media outlets to expand the reach of our message. We hope these strategies will yield better results, and will keep you posted regarding outcomes from the latest leg of CIT.
Addressing the large gaps in mental health care among underserved groups is a challenging but crucial endeavor and necessitates the incorporation of salient aspects of clients’ cultural identities. Some strategies that have already been helpful for our team included receiving the endorsement of community leaders (and including them as part of the research team), and frequent messaging regarding the availability of services to help overcome mental health stigma and treatment resistance. Other avenues that may bear fruit include expanding the reach of services in the case of virtual treatments, conducting research on the target population’s treatment preferences and barriers (and collaborating directly with the community to ensure that stakeholders are represented), and hiring enthusiastic local research coordinators who have insight into one’s community of interest and may also be able to answer questions about the project and research team.
Cite This Article
Ahmad, S., McLaughlin, M., Mamani, A. (2022). Integrating culture and religion/spirituality with evidence-based treatments for underserved groups. Psychotherapy Bulletin, 57(4), 21-26.
Ahmad, S. S., McLaughlin, M. M., & Weisman de Mamani, A. (2022). Spiritual bypass as a moderator of the relationships between religious coping and psychological distress in Muslims living in the United States. Psychology of Religion and Spirituality. Advance online publication. https://doi.org/10.1037/rel0000469
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington: American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596
Cabral, R. R., & Smith, T. B. (2011). Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes. Journal of counseling psychology, 58(4), 537.
Cook, B. L., Trinh, N. H., Li, Z., Hou, S. S. Y., & Progovac, A. M. (2017). Trends in racial-ethnic disparities in access to mental health care, 2004–2012. Psychiatric Services, 68(1), 9–16. https://doi.org/10.1176/appi.ps.201500453
Ertl, M. M., Mann-Saumier, M., Martin, R. A., Graves, D. F., & Altarriba, J. (2019). The Impossibility of Client–Therapist “Match”: Implications and Future Directions for Multicultural Competency. Journal of Mental Health Counseling, 41(4), 312-326.
Forehand, R., & Kotchick, B. A. (1996). Cultural diversity: A wake-up call for parent training. Behavior therapy, 27(2), 187-206. https://doi.org/10.1016/S0005-7894(96)80014-1
Hall, G. C. N., Ibaraki, A. Y., Huang, E. R., Marti, C. N., & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior therapy, 47(6), 993-1014. https://doi.org/10.1016/j.beth.2016.09.005
Khan, F., Khan, M., Soyege, H. O., Maklad, S., & Center, K. (2019). Evaluation of factors affecting attitudes of Muslim Americans toward seeking and using formal mental health services. Journal of Muslim Mental Health, 13(2).
Mowbray, O., Campbell, R. D., Kim, I., & Scott, J. A. (2018). Quitting mental health services among racial and ethnic groups of Americans with depression. The Journal of Behavioral Health Services & Research, 45(2), 269–279.
Randall, A. (2021). South Florida is becoming the nation’s worst place to rent. https://news.yahoo.com/south-florida-becoming-nation-worst-081500045.html
Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta‐analysis. Journal of Clinical Psychology, 74(11), 1924-1937.
Weisman de Mamani, A., McLaughlin, M., Altamirano, O., Lopez, D., & Ahmad, S. S. (2021). Culturally informed therapy for schizophrenia: A family-focused cognitive behavioral approach: Clinician guide. Oxford University Press. https://psycnet.apa.org/doi/10.1093/med-psych/9780197500644.001.0001
Wong, E. C., Collins, R. L., Breslau, J., Burnam, M. A., Cefalu, M., & Roth, E. A. (2018). Differential association of stigma with perceived need and mental health service use. The Journal of Nervous and Mental Disease, 206(6), 461–468.