Which best describes the difference between traditional healers as opposed to Western providers?

The Development of Western Psychotherapy

Western psychotherapy’s ancestry and deep historical roots come from European and US history. Given its origins, it is culturally laden with Western values and could be considered a treatment that has been developed and tailored for those from European and White American ancestry. It is important to note that 84.2% (5.97 billion) of the world’s population consists of people from non-European ancestry (United States Census Bureau, 2013). Therefore, it is important to understand whether Western psychotherapy works well with people from diverse backgrounds and whether cultural adaptations and modifications can increase therapeutic effectiveness. Given that mental health treatment is significantly underdeveloped in countries of non-European ancestry, figuring out how to meet the mental health needs of the world’s diverse population is of utmost importance.

The emphasis on a separate mind and body in the West reinforced the development of separate nosological classification, diagnostic, and treatment systems for physical and mental health. This differentiation also led to specialized research programs, evidence-based initiatives, as well as targeted funding priorities. Psychiatry eventually developed into the practice of prescribing drugs for mental illness, and psychology focused on talk therapy as a means to improve mental well-being. Eventually, the development of different theories and methods for treating mental illness led to the evolution of different schools of psychological thought.

Specifically, there have been four major waves or schools of psychotherapy (Dryden & Mytton, 1999; Enns & Sinacore, 2005). Starting with psychoanalysis in the late 1800s, Freud popularized the idea of the psyche as being composed of both the conscious and unconscious. Moreover, with the evolution of psychoanalysis came the coining of classic terms such as free association, transference, countertransference, repression, and the “talking cure.” Additionally, other terms and concepts such as the Oedipal complex, the Electra complex, penis envy, and the classic id, ego, superego were also heavily popularized—but found to be culturally biased and lacking scientific support. Over time, psychoanalysis evolved into different schools of psychodynamic thought, eventually decreasing the emphasis on psychosexual development. A stronger emphasis was placed on attachment theory and interpersonal relations, which have a stronger research foundation and may be more universally accepted.

Since the development of psychoanalytic and psychodynamic therapies, many different schools of thought developed and psychotherapy branched out into different theoretical orientations and modalities. The second wave of psychotherapy was behaviorism and emphasized learning and reinforcement through behavioral modification. The third wave consisted of humanistic and experiential therapies, focusing more on self-actualization, empathy and shared emotional experiences, and the healing power of therapists’ unconditional positive regard toward the client. The fourth wave consisted of cognitive therapy, with a strong emphasis on irrational thinking or cognitive errors, the cognitive triad (negative thoughts about the self, world, and future), and cognitive reframing. Counseling psychologists have conceptualized major schools of psychotherapeutic thought, not as waves, but as forces in counseling (Ivey, D’Andrea, & Ivey, 2011). These forces include psychoanalytic/psychodynamic, cognitive and behavioral therapies, and existential-humanistic therapies.

Recently, a fifth wave was proposed—specifically, integrative psychotherapy which combines elements from different major theoretical orientations, with an emphasis on retaining empirically supported therapeutic mechanisms (Norcross & Goldfried, 2005). If a fifth wave were to become widely established and to become fully accepted, then this integrationist approach may benefit from incorporating multicultural issues. In fact, this is a prime opportunity to integrate culturally competent therapy and cultural adaptations into mental health care—especially since the vast majority of practicing therapists utilize an integrated therapeutic approach; albeit, not necessarily including the same mechanisms stressed by Norcross.

It is important to note that Western psychotherapies are already culturally individualized for White Americans. Specifically, they were developed for and continually adapted to the needs of White or European American populations. In order to provide equitable treatment, we need to be able to individualize and tailor treatments for people of color as well. By studying culture, we come closer to understanding universal truths about human behavior and the treatment of mental disorders, as well as gaining a better understanding of the diversity of culture-specific issues. Furthermore, we begin to identify culture-universal healing mechanisms of psychotherapy that can be generalized to all groups. Certain fields of psychology have begun to strongly prioritize the role of culture in mental health. For example, the field of counseling psychology has noted that the fourth force of counseling psychology is the incorporation of multicultural issues—specifically, culturally effective therapies that incorporate multicultural and feminist perspectives (Ivey et al., 2011).

Whether the next major wave or force of psychotherapy and counseling is integrationist or multicultural, there is no doubt that psychology is heavily laden culturally. The vast majority of psychological research has primarily focused on White Americans or those of European ancestry, and whether treatments will work as effectively with non-White populations is an empirical question that needs to be further explored. However, whether cultural adaptations can increase the effectiveness of psychotherapy, not only in terms of symptom change, but also in terms of client engagement, treatment satisfaction, stronger working alliances, increased feelings of comfort, and reduction of premature dropout is also an important area to explore.

Much more work needs to be done in studying cultural issues in mental health for ethnic minorities, international populations of color, as well as immigrants and refugees. It is important to study culture and broaden the populations whom we study in mental health because the study of culture informs psychological science. Just as the study of psychological science (eg, social psychology, cognitive psychology, development of psychology) informs clinical science, the incorporation and study of culture are integral to understanding human behavior. The study of culture can help inform both the psychological science and the clinical science of defining and treating mental illness.

Relaxation: PMR

This is a commonly used therapeutic technique that has been widely incorporated into Western psychotherapy. It consists of a series of tensing and releasing different parts of one’s face, body, and extremities. Therapists are free to teach various types of PMR and to tailor it to the various parts of the bodies where clients hold more stress. For example, if clients have a lot of headaches, incorporation of tensing and releasing different aspects of the face may be beneficial. If clients hold a lot of tension in the shoulders, PMR that focuses more on the neck, shoulders, and scapula can provide targeted relief. Clients are taught to tense and relax different parts of the body for 10–15 s. However, the actual length of time can be collaboratively modified by the therapist and/or the client to achieve maximum benefits for the client’s particular problem.

10.18.5.3 Treatment/Cure

Traditional healers use a variety of techniques that have been empirically proven effective in Western psychotherapy. One of their many strengths is their ability to engender faith and hope in the therapeutic process (Frank, 1978; Yalom, 1995). Especially for spiritual healing, it is important for the client to have faith and hope in the process. Doubt and the lack of faith do not lead to significant therapeutic gains. In fact, psychotherapy and medical treatment in all societies benefit from faith and hope long before the other therapeutic factors kick in. Thus, the ability of traditional healers to mobilize their clients” hope becomes an important variable in the therapeutic process.

Traditional healers are also holistic in their approach. Treatment usually combines the physical, social, and spiritual in an effort to restore harmony to the client. Herbal treatment is employed where necessary and social and spiritual interventions are made as appropriate. Whenever necessary (although very infrequently) referral is made to another healer. In all instances, family and close neighbors participate in the treatment, making it easy for the healer to employ all available resources for support and effective treatment. What is good for the client is decided by all of them within the context of the plural medical systems; choosing to use the systems concurrently or simultaneously.

Treatment techniques also include traditional music and dancing, therapeutic rituals and sacrifices, suggestions, hypnosis, and other techniques similar to cognitive-behavioral approaches. The important thing throughout all counseling is the attention given to interpersonal relationships, significant others, and contextual issues.

1.04.3.3 Africa

A brief explanation of African traditional healing is required to contextualize the accreditation and licensing process for psychotherapy in Africa. Traditional healing is culturally and regionally diverse, but the umbrella term relies “…exclusively on past experience and observation handed down from generation to generation, verbally or in writing…health practices, approaches, knowledge, and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercise, applied singular or in combination, to treat, diagnose and prevent illnesses or maintain well-being” (WHO, 1976, p. 8). For centuries, traditional healers have been treating social and health-related problems for individuals throughout Africa and “talking catharsis” is hardly new. The training of traditional and faith healing practices is commonly taught through church services or by elders, and training is often unregulated. In many African countries, certain health problems have been reported to be treated by traditional healers rather than health centers (e.g., fever, pain, depression) and traditional healers are the main source of health care sought after health centers or unresolved issues (Jidda et al., 2010). Traditional healing therapies are often referred to as “African Psychotherapy” to differentiate them from “Western” psychotherapies, such as CBT, psychoanalysis, and interpersonal therapy (Jidda et al., 2010).

The contemporary practice of psychotherapy in Africa began through an emphasis on education psychology in universities, and some regions have now grown to include undergraduate and postgraduate degrees in counseling, clinical and other psychological disciplines (see discussion in Spedding et al., 2017). However, there is little emphasis on the disciplined and scientific training of Western psychotherapy and there are still many countries where psychotherapy or psychology training programs are either scarce or non-existent, such as those in Central Africa (Spedding et al., 2017). If psychology training is regulated at a national level, program accreditation typically falls under the general jurisdiction of education organizations, rather than specific or independent bodies for psychotherapy (Moodley et al., 2013). Few countries have professional associations or laws that regulate licensing and the criteria for membership is broad. To illustrate examples from West, East, and North African countries (Moodley et al., 2013); no academic psychology programs in West Africa are state regulated and Nigeria is the only country with a professional psychology organization. In East Africa, some countries offer postgraduate degrees in psychology (e.g., Zimbabwe) while others only offer training in counseling (e.g., Kenya), yet with no licensing laws. While most North African countries offer at least undergraduate education in psychology, Egypt is the only country with a licensure law for psychotherapy specifically. Egyptian law mandates training requirements through either a diploma of psychiatry or neurology, a psychology postgraduate degree with minimum 2-years of clinical practice, or specialized certification through local or international psychotherapy organizations.

In Southern Africa, countries (with the exception of Kenya) have a greater emphasis on Western psychotherapy and have incorporated psychotherapy training into undergraduate and postgraduate psychological degrees (e.g., Botswana, Zambia, Zimbabwe, see discussion in Moodley et al., 2013). Education programs are regulated and accredited by health and education ministries, and training models encourage an SP philosophy and curriculum (Moodley et al., 2013). In particular, the psychotherapy training system in South Africa has established the Board of Psychology (BoP) as the professional accrediting body, and psychologist registration is obtained after postgraduate study, supervised practice, and completion of the BoP Examination (Health Professions Council of South Africa [HPCSA]). HPCSA and subsidiary professional psychological organizations in South Africa also advocate for EBPP in training programs and there has been a rise in the psychological research literature from South Africa (see review in Jidda et al., 2010). Studies have reported positive outcomes in RCTs of behavioral interventions for behavior change in HIV incidence (Jewkes et al., 2006) and cognitive therapy for anxiety and depression (Osinowoet al., 2004). New psychotherapy models have also been developed through the integration of Western and African psychotherapy theories and techniques (e.g., Ubuntu therapy, Van Dyk and Nefale, 2005).

Chapter Goal #3: Facilitating Self-Care in the Context of Social Responsibility

When trying to figure out how to best work through life’s difficulties and decide on the “wisest action,” there is a lot of push and pull between balancing one’s own needs and thinking about the needs of others (eg, friends, families, and partners). This is especially relevant for Asian heritage populations because of the collectivistic (vs individualistic) and interdependent (vs independent) cultural orientations, which place a greater emphasis on social context, understanding, and meeting the needs of others. The notion of attending to one’s social responsibility to the family versus addressing one’s own needs and self-care (eg, self–other differentiation and prioritization) can sometimes be at odds with the value of Western psychotherapy. Specifically, psychotherapy was created from an individualistic value orientation, and places a greater emphasis on an individual’s rights, needs, and responsibilities.

For example, a therapist who is less sensitive and knowledgeable about Asian heritage populations may push a teenager or young adult to focus on the client’s interests, needs, and priorities (eg, you should be able to study and choose whatever you want, or you should be able to date at this age because this is what people are supposed to do). However, therapists can easily forget that they too can be culture-biased and speak and interpret issues through a Western or individualistic cultural lens. As a result, youth and young adults who come in seeking help for resolving family problems are often pushed in the direction of greater individuality, becoming more acculturated, and focusing on their own needs, with less or no consideration of parental and family cultural values and priorities. Unfortunately, the Asian or collectivistic cultural lens may be devalued or ignored, thus increasing problems for the individual who still needs to negotiate their needs in a collectivistic family context. This can potentially undermine Asian heritage parental authority and concepts of filial piety. Moreover, it could also challenge cultural values that parents are trying to retain, and increase further conflict between children and parents. This is especially important because many family problems and conflicts among immigrant families are caused by acculturation-gap-related issues such as cultural value differences between parents and youth. Therefore, the best solution needs to have some consideration of both cultural value orientations, and may need to prioritize bicultural perspective and understanding.

For example, if a college student goes home and tells their parents that they can study and do whatever they want, and then proceeds to criticize their parents for not understanding and being controlling, this can create even more problems within the family. The student may even say that “even my therapist thinks you are unreasonable and violating my personal rights,” which can actually increase parent–child conflict, lead to further emotional distancing, and decrease the parents’ perceptions of the benefits of their child being in therapy because they feel undermined. When working with families with varying acculturative levels, understanding and figuring out how to best address the impact of individualistic and collectivistic cultural orientations on family dynamics is of utmost importance. Therapists working with individuals and families from collectivistic cultural backgrounds need to be highly cognizant of the cultural biases and pressures to assimilate to individualistic values and priorities. In order to address this issue, the treatment manual includes a section on understanding how to balance a person’s rights versus familial responsibilities. The notion of pursuing one’s own needs versus addressing social obligations and collectivistic notions of self-sacrifice for the greater good of the family can be at odds and therefore need to be considered when culturally adapting therapy.

II.B. Cognitive Mastery

All therapies, in some measure, provide the patient with cognitive mastery, whether they offer the classical, well-timed interpretations of Freudian psychoanalysis or, as in Albert Ellis's rational-emotive therapy, have the therapist “sing along” with the patient a litany of the patient's irrational false beliefs. Cognitive mastery thus refers to those aspects of treatment that use reason and meaning (conscious or unconscious) over affect as their primary therapeutic tools, and that attempt to achieve their effects through the acquisition and integration of new perceptions, thinking patterns, and/or self-awareness. A prototype of a cognitive change agent is the therapeutic application of insight, defined as the process by which the meaning, significance, pattern, or use of an experience becomes clear—or the understanding that results from this process.

Historically, primitive faith healing and the early stages of psychotherapy were very much alike in that neither initially attempted to provide insight. However, while faith healing continued only to maximize suggestion (essentially through affective experiences), Western psychotherapy became distinctive in departing from the primitive mode by moving into a second state—to correct problems by explaining them rationally. Going somewhat farther along this line, although the foundation of all therapies is the phenomenon of therapeutic suggestibility, primitive therapies are based almost entirely on irrational belief and dependency, whereas Western scientific therapies are more often founded on rational insight and independence.

Insight (through free association and interpretation) has been considered a sine qua non of the psychoanalytic process, yet all psychotherapies provide opportunities for change through cognitive channels—by means of explanation, clarification, new information, or even confrontation of irrational and self-defeating beliefs. Behavior therapies, once considered the antithesis of an insight-oriented approach, have increasingly incorporated cognitive learning techniques into their repertoire. Over time the behavioral model of treatment has radically changed from that of conditioning to social learning and information processing. The behavioral technique of thought stopping developed by David Wolpe, a cognitive variation of classical conditioning methods to extinguish anxiety, can be considered an early example of this change in approach. Albert Ellis's rational-emotive therapy, William Glasser's reality therapy, and Aaron Beck's cognitive therapy all share in direct attempts to correct stereotyped, biased, or self-defeating thinking patterns and dysfunctional attitudes and values, whereas others, like Victor Frankl's logotherapy and William Sahakian's philosophical therapy, are directed to the most profound cognitive reappraisals of life and its meaning. Even the most actively experiential therapies use cognitive techniques; for example, Gestalt “experiments” can be considered cognitively as a structured interpretation.

Thus, cognitive mastery as a universal therapeutic agent may be defined as acquiring and integrating new perceptions, thinking patterns, and/or self-awareness, whether this is effected through interpretations, explanations, practical information, or direct confrontation of faulty thoughts and images. In contrast to affective experiencing, it serves as a rational component of treatment— to inform, assess, and organize change and to establish or restore ego control. Despite their therapeutic utility in providing a new perspective, meaning, or way of thinking, cognitive approaches are not always sufficient as change agents. Put succinctly, not all change is attributable to insight and not all insight leads to change.

In the final analysis, the criteria for attaining lasting insight must be judged by its personal and social consequences. In short, new thinking (or insight) that has been achieved in therapy must be worked through and incorporated into one's actions and behavior in everyday life; it must be transferred from the structured and safe confines of the therapist's office and put into active practice in the real world outside treatment. Thus, cognitive mastery, like affective experiencing, needs to be complemented by other therapeutic change agents. More specifically, although an affective experience may prepare the patient for cognitive learning, the latter requires gradual assimilation and behavioral application of new input, if therapeutic effects are to endure.

Conclusion

As we move ahead, we need to keep these cultural and clinical complexities in mind. We need to be careful not to stereotype, but we also need cultural information and knowledge that help us better understand the cultural context of what is occurring. We need to have cognitive flexibility and not internalize stereotypes, but at the same time use our cultural knowledge to help us ask important questions that need to be assessed and evaluated. Although cultural or group-specific information may be provided in the manual, the practitioner must remember to deconstruct stereotypes and individualize services for their clients. This requires assessing the complexities of identity, and understanding the wide variation and diversity that exist within any particular ethnic or cultural group. This may also require breaking from the norms that we have been taught during our graduate and clinical training, and engaging in behaviors that might help facilitate a stronger working relationship with our client.

For example, some therapists may feel like offering a client a cup of tea and having a drink in the therapy room may be an unwanted “object” in the therapy room and interfere with the therapeutic process. Other therapists may feel like disclosure of any kind impedes the client’s ability to experience the therapist as a blank slate or neutral body. Albeit they may not be a norm for Western psychotherapy, sometimes these practices can be culturally normative and necessary. Offering tea can help reduce client discomfort and anxiety for being in such mental health treatment, and can also help facilitate a positive working relationship. Moreover, disclosing therapist cultural heritage information can also help foster closeness or serve as a cultural bridge, such that the client is able to disclose information to the therapist because they are no longer perceived as a stranger versus somebody who they are interpersonally close with. These and other complexities must be carefully evaluated for their costs and benefits. Not answering some of these questions may be perceived as rude and lead to relational distancing. However, answering them can also be a pitfall if the therapist does not understand the client’s rationale for asking such questions (which can be driven by clinical and cultural issues), or if the therapist does not evaluate the impact on clinical processes or the therapeutic relationship.

In addition, just because a therapist is of the same cultural background as the client does not mean they will be more effective working with a person of the same ancestry. Although there is some research indicating the ethnic match can be important, it is the therapist’s cultural competency that is the true mechanism that improves outcomes. It is also important to keep in mind that the majority of ethnic minority therapists are trained in the Western system of psychotherapy, and have had little formal training on culturally adapting therapy. A number of complexities can affect ethnic match and ethnic nonmatch therapeutic relationships, including the notion of ethnocultural transference and countertransference (Comas-Diaz & Jacobsen, 1991).

Remember that ethnic minorities and nonminorities are all in different stages of their ethnic identity development, which can affect how they interact, perceive, and interpret the therapeutic relationship and the client’s problems. These issues need to be considered, especially since the notion that a therapist who doesn’t know much about a client and can just refer them out to somebody else who matches the client’s ethnic background, leaving many clients without accessible care. Although well-intentioned, it is important to remember that there is a shortage of ethnic minority mental healthcare providers. The “referring out” notion, when working with non-White populations, can reinforce a nonresponsibility-taking, “passing the buck” mentality by practitioners. Practitioners need to put forth effort in learning about cultural issues as they do for clinical issues. As culturally competent therapists who are continually learning and developing practical skills in cultural adaptation, we need to conscientiously evaluate and assess for these cultural–clinical complexities and be flexible when working with people who may have different worldviews.

Chapter Goal #1: Checking in to Make Sure Your Client Is Fully Engaged and Understands the Collaborative Nature of Psychotherapy

Asian heritage populations are often reluctant to seek mental health treatment and sometimes feel uncomfortable when they seek help. Consequently, it is important to both initially and periodically check-in with the client to make sure that they understand the collaborative nature of psychotherapy and are fully engaged. The culturally adapted treatment manual does so by conducting weekly checks-ins and reviewing take-home exercises. There are several reasons for this.

First, conducting weekly check-ins help clients feel more engaged and underscores that their therapist cares about their well-being and life circumstances. Second, it provides the client with an open space that helps them feel more comfortable talking about their problems and feelings with a stranger, and also creates a routine with expectations that discussing private issues is an important part of the therapy process. Third, it reduces the discomfort and awkwardness at the beginning of therapy when many Asian heritage clients may not know what to say or do. Fourth, it makes the clients aware that the therapist will follow-up on take-home exercises and that the practice of skills is essential for getting better and achieving one’s goals. This will help reduce the likelihood of take-home exercise noncompliance. Because Asian heritage populations may have more difficulty discussing their problems with nonfamily members and people who they do not know well, therapists showing interest and setting the expectation for client–therapist collaborative efforts is an integral cultural adaptation that sets the tempo for future sessions.

Therapists need to be cognizant that Western psychotherapy may be foreign to Asian immigrants, and that clients may need more time and understanding before they feel comfortable freely expressing themselves in treatment (Hwang, 2006). Asian immigrants may be less culturally inclined to talk about their problems with a person with whom they have not developed a close relationship. However, this does not mean that they are unable to express their emotions; rather, a stronger therapist–client alliance may need to be established before clients are willing to open up. Understanding social and cultural traditions and etiquette may require that therapists take a greater initial investment to effectively join and engage with the client (Lee, 1997). This may influence the topics and tempo of the initial treatment sessions.

Moreover, many Asian cultures place great importance on hierarchical relationships, respect for authority figures, and social structure and harmony (Lin, 2002; Zhang et al., 2002). Because of this, it can be not only beneficial but also necessary for therapists to exhibit authority and leadership skills by setting structure and expectations for therapy. Asian heritage populations see the therapist as an expert or authority figure that provides guidance in solving their problems, often expecting the therapist to tell them what to do. This results in the expectation that the therapist will be more proactive in providing direction, giving advice, and teaching skills and practices that provide immediate symptom relief. Moreover, the natural inclination of many clients is to assume that it is the responsibility of the therapist to ask them questions, and not the role of the client to ask questions of the therapist. This is why psychoeducation and setting expectations early on is so important for Asian heritage clients.

Some clients may even feel that asking questions of authority figures is equivalent to directly challenging or disrespecting them. As a result, they are also less likely to openly disagree with the therapist. Some Asian heritage clients may also appear passive, quiet, and reserved, because of cultural differences in relation to authority figures. Consequently, therapists who are unfamiliar with the client’s cultural background may be more likely to misinterpret culturally influenced communication and expression styles and see Asian heritage clients as being uncooperative, avoidant, uncommunicative, or not taking initiative for self-care. These issues can also interact with clinical symptoms (eg, depression), which may reduce the energy, motivation, and how much clients socially interact. Therapists need to keep these questions in the back of their mind as they make clinical interpretations and formulate treatment plans.

It can also be beneficial if the therapist capitalizes on the client’s perception of them as an expert authority figure. This can be a culturally normative method of increasing client engagement and compliance with take-home exercises. Setting treatment expectations early can help clients be more willing to talk about their feelings and problems, ask questions, collaborate, express their needs, and even openly disagree with the therapist. This is especially important since many traditional and indigenous medicines are less collaborative, more authority-driven, and tend to be more top-down than Western psychotherapy.

There are many ways to improve the client–therapist relationship. Changing the conceptual framework of psychotherapy and the vocabulary that one uses to describe and introduce treatment can help clients better relate to therapy and improve the therapeutic alliance. For example, during phase I focus groups, we discussed utilizing a comparative metaphor between physical therapy and psychotherapy as a way to help reduce stigma, understand the importance of treatment, help clients understand therapeutic tasks and homework exercises, and improve the therapeutic working relationship. Clients responded well to this metaphor and culturally adapted terminology as evidenced during phase IV of the Formative Method for Adapting Psychotherapy (FMAP) (treatment testing phase). This helped reduce stigma and helped clients understand the importance of treatment.

Phases I (focus group discussions and initial treatment development phase) and IV (treatment testing phase) of the FMAP also help reinforce that using the words “exercise” and “practice,” rather than “homework,” can be an effective cultural modification which is more acceptable and aligns with the physical therapy metaphor. For example, one therapist half-jokingly stated Asian heritage populations have such high academic pressure and do too much homework while growing up that they may have an aversive reaction to hearing the word “homework” as an adult. The room became filled with laughter and other therapists reiterated this idea, noting that Asian heritage populations have done enough homework and don’t want to do any more as adults. Therefore, in the treatment manual homework was called “take-home exercises” or “take-home practice.” Similarly, utilizing the terms practice and exercise can also be beneficial and effective for children and adolescents, who may already have “too much homework” to complete and may balk at the idea of doing more. It is important to help clients understand that comprehension alone is not sufficient to stimulate change. Practice is necessary to facilitate improvements, skills development, and consolidate gains.

Check-ins also have a direct tie-in to therapeutic improvements. They provide opportunities to identify and troubleshoot barriers for why clients may not be completing their take-home exercises. For example, noncompliance could be related to emotional (eg, I don’t feel good), cognitive (eg, nothing will change, there is no point in trying), physical (eg, I’m too tired and don’t have the energy), behavioral (eg, drinking too much and having a hangover), organizational skills (eg, not having a structured action plan that will facilitate exercise completion), and clinical (eg, feeling too depressed) difficulties. These barriers may impede clients from practicing their take-home strengthening exercises, and consequently limit the clinical effectiveness of the therapy. Utilizing a check-in provides structure and set the tempo for a collaborative psychoeducational approach, which aligns well with Asian heritage values.

Since this is the first session where there is a “weekly check-in and review of take-home exercises,” it is also important to “query clients about their initial reactions to therapy.” When working with Asian heritage populations, this is an especially important cultural modification since they may feel uncomfortable in treatment and may be more likely to drop out. Inquiring about their experiences thus far and asking if there is anything that the therapist can do to better meet their needs helps establish and reify the collaborative relationship. It also helps clients understand that they can ask questions anytime during treatment, and reinforces the problem-solving focus of the culturally adapted treatment.

Examples of Culturally Adapted Interventions

A number of researchers have already begun culturally adapting psychotherapy and studying its benefits. Below I provide a brief review of some of the interventions that target different areas, including adaptations for specific ethnic groups, modifications to psychotherapy that address immigration and bicultural effectiveness, as well as indigenous treatments that have developed from their cultures of origin (which tend to be significantly different from traditional Western psychotherapies). However, it goes beyond the scope of this book to review all of the research that has or is currently being conducted in this arena. However, a recently edited book written by Bernal and Domenech Rodríguez (2012) provides an excellent overview of efforts to culturally adapt psychotherapy for a number of ethnocultural groups. This book serves as an excellent resource to understand how various scientist-practitioners have begun to address this challenging but important endeavor. (See Bernal & Domenech Rodríguez, 2012 for a more extensive review of recent projects.)

One of the first studies was a culturally adapted cognitive-behavioral and interpersonal treatment for depressed Puerto Rican youth, which has been shown to be efficacious in RCTs (Rossello & Bernal, 1996, 1999). Kohn, Oden, Munoz, Robinson, and Leavitt (2002) adapted a manualized group CBT intervention for use with low-income African American women. They utilized both structural change (eg, limiting the group to African American women, adding experiential meditative exercises, changing some of the language used to describe CBT) and didactic adaptations (eg, attending to four issues salient to this group: creating healthy relations, spirituality, African American family issues, and African American female identity) in modifying the treatment outcomes. Kumpfer, Alvarado, Smith, and Bellamy (2002) have used various approaches to adapt the Strengthening Families Program for use with multiple ethnic groups.

Others have developed interventions to target specific issues that acculturating immigrants might encounter. These approaches address diversity issues related to the culture of origin as well as issues related to adjustment, acculturation, and cultural transitions to the United States. Because many immigrants encounter adaptation and acculturation problems, instead of focusing solely on cultural differences with the client’s culture of origin, adapted treatments need to be flexible in addressing cultural changes over time. This is especially important since many minorities share a similar immigration experience that could be targeted in prevention and treatment programs.

These programs include Bicultural Effectiveness Training (BET) and Family Effectiveness Training (FET) that target intergenerational conflicts exacerbated by acculturation and adaptation problems (Szapocznik, Santisteban, Kurtines, Perez-Vidal, & Hervis, 1984; Szapocznik et al., 1989) and the Strengthening of Intergenerational/Intercultural Ties in Immigrant Chinese American Families (SITICAF) (Ying, 1999). FET was tested among a Hispanic population and was able to both reduce child behavior problems and improve general family functioning and interactions compared to a control condition (Szapocznik et al., 1989). Among Cuban American families, BET was found to be just as effective as a preexisting therapy for dealing with adolescent conduct disorder and social maladjustment (Szapocznik, Rio, Perez-Vidal, Kurtines, Hervis, & Santisteban, 1986). Though tried among a smaller sample, SITICAF was also found to be effective in improving intergenerational relations, and for parents, a sense of responsibility and control (Ying, 1999).

Some scholars have also begun developing treatment modalities that favor the particular values and traditions embedded in the culture of origin. These programs are not direct cultural adaptations, but interventions that have developed out of cultural healing systems. For example, “cuento” or folktale therapy for Puerto Rican youth involves telling and then discussing fables that are culturally and developmentally relevant (Costantino, Malgady, & Rogler, 1988). Cuento therapy has been shown to have a positive psychological effect on Hispanic/Latino children and adolescents, especially with regards to decreasing anxiety (Costantino & Malgady, 1996; Costantino, Malgady, & Rogler, 1986; Ramirez, Jain, Flores-Torres, Perez, & Carlson, 2009).

In addition, Morita therapy and Naikan therapy for the Japanese both focus on repairing the interpersonal relationships that are key to Japan’s collectivist society (Morita, Kondo, & LeVine, 1998; Reynolds, 1980). Morita therapy was developed in the early 1900s to soothe neurotic interpersonal anxieties, while Naikan therapy became popular a few decades later as an extension of Buddhist thought (Hedstrom, 1994). However, very few outcome studies have been conducted, and those that have are not always methodologically rigorous nor do they implement RCT methodologies. Still, there is some evidence that Naikan therapy can help patients with depression (Sengoku, Murata, Kawahara, Imamura, & Nakagome, 2010). Morita therapy has also been used to some effect in conjunction with pharmacological treatments to treat obsessive-compulsive disorder in China (Jie, Jian-Qing, & Qiang, 2005; Mei, Zhu, & Chen, 2000). Also in China, Zhang and colleagues combined elements of cognitive therapy with Taoist philosophy and developed Chinese Taoist Cognitive Psychotherapy for Chinese clients with generalized anxiety disorder (Zhang et al., 2002).

Cultural drivers in Latinx mental health treatment utilization gaps

In terms of cultural drivers of Latinx mental healthcare disparities, the literature often points to culturally influenced beliefs and attitudes toward mental health etiology and treatment (Bermúdez, Kirkpatrick, Hecker, & Torres-Robles, 2010; Interian et al., 2010). Latinx individuals may endorse beliefs that can be at odds with Western psychology’s view of mental health etiology (Jimenez, Bartels, Cardenas, Dhaliwal, & Alegría, 2012; Raglin Bignall, Jacquez, & Vaughn, 2015). Although Western psychology views mental health issues as both environmentally and biologically based and potentially chronic and significantly impairing, Latinx individuals can often view mental health issues as exclusively environmentally based (e.g., deficits in interpersonal relationships, loss of work, insufficient faith in God), temporary, and surmountable with help from loved ones, inner strength, or prayer (Caplan & Cordero, 2015). These differing views on mental health etiology can discourage Latinx individuals from seeking professional help for mental health needs, thereby furthering the treatment utilization gap (Mendoza, Masuda, & Swartout, 2015; Rastogi, Massey-Hastings, & Wieling, 2012). Latinxs also may hold collectivistic values placing the well-being of one’s community above the self and favoring a reliance on community support to achieve well-being (Mendez & Cole, 2014). Together, these values and beliefs can place Latinx individuals at odds with Western psychotherapy’s focus on addressing the individual’s difficulties without necessarily always taking into account how the individual’s issue impacts their family or larger community, and vice versa.

These values and beliefs often result in Latinxs seeking mental health support from known community entities (e.g., family, church) before turning to professional help (Caplan & Whittemore, 2013; Marquez & Ramirez Garcia, 2013). Once in the mental health system, however, Latinxs may also encounter a lack of cultural congruence leading to limited buy-in in mental health services and potentially early termination (Villatoro, Morales, & Mays, 2014). These factors may also contribute to mental health stigma whereby mental health services are regarded as being only para locos (for crazy people), and so mental health services may be avoided due to fears of becoming ostracized from one’s community and its supports (Vargas et al., 2015). Thus, it is incumbent upon mental health providers and researchers alike to be cognizant of the unique cultural factors that play a role in stigma and help-seeking behaviors within this community, as well as how to engage the community and not just the individual in finding how to best support the well-being of Latinx communities.

Further, Latinx values like familismo, personalismo, and simpatia are seen as manifestations of collectivistic values that may serve as “double-edged swords,” in that they can serve both a protective role against mental health issues and promote treatment engagement, but they can also foster beliefs and attitudes that negatively impact engagement in mental health treatment (Stein & Guzman, 2015). For example, depending on whether one’s family/community holds positive or negative views toward mental health treatment, endorsing high levels of familismo—a Latinx cultural value characterized by strong identification and attachment of individuals with their nuclear and extended families as well as strong value placed upon maintaining loyalty and reciprocal relationships and solidarity among members of the same family (Stein, Cupito, Mendez, et al., 2014)—may result in either increased sense of solidarity and support or increased stigma and exclusion from much needed systems of support, respectively. Indeed, research has shown that in some instances familismo has been associated with both increased treatment adherence and attendance or increased reluctance to seek out treatment for fear of criticism and reflecting poorly on the family (Caplan & Whittemore, 2013; Martinez, Interian, & Guarnaccia, 2013). Similarly, personalismo and simpatia, which dictate the importance of close relationships and maintaining interpersonal harmony, have been associated with both positive and negative outcomes in Latinx treatment engagement. Although, on the one hand, these values can help Latinx individuals to forge strong therapeutic alliances with their providers, on the other hand, they can also preclude Latinx individuals from voicing disagreements within therapy for fear of upsetting the practitioner, and instead, quietly disengaging from therapy or dropping out of treatment prematurely (Cortes, Mulvaney-Day, Fortuna, Reinfeld, & Alegría, 2009).

In addition to cultural values, immigrant optimism may also play an important role in mental health treatment seeking. Immigrant optimism is defined as the optimistic and relative perspective that many Latinx immigrants take toward their lives in the United States. In essence, through a dual frame of reference, Latinx immigrants, especially those who faced daily danger, abject poverty, or limited resources, consider their current stressors in light of these past experiences (Chen & Miller, 2012), and those experiences may make it less likely that they seek out mental health support as they perceive their current situation to be better than their past. However, immigrant optimism can also facilitate adaptation. Because many Latinx immigrants migrated to the United States in search of a better life for their families, these families may also be motivated to withstand the hardships associated with immigration as well as harboring the hope that things will improve (May & Witherspoon, 2019). Immigrant optimism may function similarly to the shift-and-persist model where those facing economic stressors show better health outcomes due to the ability to cognitively shift away from focusing on stressors and persist by turning their attention to the future with hope (Chen & Miller, 2012).

In sum, the literature on cultural factors associated with Latinx mental healthcare gaps suggests that research needs to take into account the significant variability inherent in the population. Findings suggest that Latinx cultural values and beliefs on mental health are not necessarily incompatible with Western mental healthcare and can potentially be harnessed to facilitate treatment. Because these cultural factors play a role in mental health treatment seeking, it requires research-community partnerships to identify solutions that are culturally responsive, take advantage of cultural strengths, and address the issues unique to each Latinx community. Involving Latinx community members as partners will foster research that incorporates the Latinx community’s perspectives on these risk and resilience processes unique to the context in which they live. Further, given the importance of the Latinx community to the well-being of individuals, these partnerships will be most effective in targeting mental health disparities by reducing stigma, developing mental health programs that meet the needs of the community, and increasing capacity and equity within the Latinx community. In the following, we review how past approaches have attempted to reduce mental healthcare disparities through treatment adaptation frameworks, highlighting equitable approaches, namely CBPR and iterative CAM approaches to treatment adaptation (Barrera et al., 2013; Lau, 2006; Minkler & Wallerstein, 2008).