Culturally Informed Therapy for Schizophrenia: A Review

Diversity is not an adjunct descriptor of the U.S. population, but rather, it is a fundamental construct of our country’s demographics which is predicted only to increase. As stated in our nation’s preamble, it is our duty to “establish justice and promote the general welfare” of American people, which includes the protection of our nation’s most vulnerable identities. Thus, it is equity that holds the power to protect our nation’s people, as diversity without equity often breeds injustice.

The realm of psychological science is not exempt from this obligation to provide inclusive and affirming care, and it is held to this standard by its highest governing body – the American Psychological Association (APA). The APA has been a stark and steadfast supporter for the administration of culturally responsive care by all clinicians who practice under its jurisdiction. Over years of instruction, the APA has continually cited the use of culturally responsive practices as a necessity, not solely an option, to proactively address the unique needs of our increasingly diverse societies¹. Specifically, they state that, “as society continues to become more and more culturally diverse, mental health providers must continually engage in ongoing self-assessment related to knowledge, skills and abilities to provide culturally responsive care”². The administration of culturally responsive care supersedes surface-level cognition by encouraging action against systemic inequities that hinder provider-patient relationships. Such interventions seeking to thwart systemic inequities (e.g., culturally responsive trainings or manuals) have fostered improvements in mental health outcomes³, reduced identity-based disparities³, and illuminated unconscious biases and beliefs that muddy provider-patient relations⁴. These practices are necessary components to overthrowing unjust principles in clinical practices, and they exemplify genuine, innovative methodologies that heed Diversity, Equity, and Inclusion (DEI) principles accorded by the APA.

One such intervention is the 2021, Clinician Guide for Culturally Informed Therapy for Schizophrenia: A Family-Focused Cognitive Behavioral Approach by Amy Weisman de Mamani, Merranda McLaughlin, Olivia Altamirano, Daisy Lopez, and Salman Shaheen Ahmad⁵. The authors provide clinicians an idiographic approach to administer a 15-week, culturally responsive, family therapy protocol (hereby referred to as CIT-S) to support both patients diagnosed with schizophrenia and their familial units. A new standard is interwoven through the pages of this manual, as clinicians are encouraged to transcend mere acknowledgement and celebrate patient identities, viewpoints, and cultural backgrounds. Through CIT-S, the authors uplift culture by citing the “mounting evidence that doing so is associated with greater well- being, particularly among ethnic minorities”⁵. As such, the manual highlights the need to celebrate nuances of cultural and ethnic variables that influence mental health outcomes post-treatment (e.g., the role of individualistic and collectivistic societies on the influence, course, and maintenance of positive mental health outcomes post-treatment).  CIT-S has elicited widespread praise from reviewers, as they applaud the author’s comprehensive presentation of knowledge in three key areas: 1) Background (i.e., need for culturally responsive care in psychology, specifically for the treatment of schizophrenia), 2) Research-Based Protocol and 3) Treatment Tools.

Background

The authors wonderfully depict their dedication to inclusive intervention strategies by positioning their DEI orientation at the forefront of their manual. Specifically, the authors seek to strengthen the following constructs through the execution of CIT-S: cultural networks, religion/spirituality, and familial units.

Cultural networks

The authors regard cultural networks as an integral aspect in the maintenance of patient

well-being throughout the course of treatment. Specifically, they reference collectivistic (i.e., “a social pattern in which members perceive themselves as part of a collective, such as family, co- workers, etc.⁵”) and individualistic (i.e., a social pattern that prioritizes “independence and uniqueness”⁵ such as “in mainstream American culture”⁵) networks as potential harbingers of patient mental health trajectories. For instance, expressed emotion (EE; negative emotionality expressed by a family member towards a patient⁵) is cited as an important treatment target that materializes differently across collectivistic and individualistic networks. The authors suggest that strong, healthy collectivistic units may correlate with lower EE. Thus, they encourage viewing EE as a protective factor in mitigating course severity among patients with schizophrenia. Further, the importance placed on connection in collectivistic societies is thought to foster vital support mechanisms (e.g., empathy) that lead to positive treatment outcomes for patients with schizophrenia. Drawing on these findings, the authors astutely embed collectivistic principles into CIT-S to replicate protective components found within greater society into the therapeutic setting. Doing so elicits the following message in the protocol: Healing is not a solitary road. Rather, familial units must transform into the road that uplifts and supports patients through their journeys.

Religion/Spirituality

Interweaving religion/spirituality (R/S) into treatment protocols has long been a point of contention in psychological research⁵. A deeply personal and historically divisive construct, religion has at times mirrored its own biblical text (i.e., Luke 17:12-24), resembling the leper no man nor researcher has sought to touch. Despite this daunting precedent, the authors regard R/S as an underutilized force, referencing literature that illustrates the positive mental health impacts (i.e., reductions of anxiety, depression, and substance use) of including religious components into treatment protocols. To be clear, religion is not CIT-S’ Excalibur, rather, it is an opportunity for clinicians to draw on a patient’s foundational principles using a non-judgmental stance. Accordingly, the authors interweave the element of spirituality into the mix, stating that “CIT- S is not tied to any specific ethnic or cultural group and is instead uniquely tailored to the beliefs, values, and traditions of the participants being served”⁵. As such, the authors highlight two primary goals in their R/S modules: 1) counteract a patient’s potentially deleterious leanings on R/S, and 2) utilize positive R/S outlooks to improve life satisfaction. This duality allows authors to remain neutral in the treatment process, as they are encouraged to objectively point out harmful and highlight positive R/S viewpoints. Overall, the use of R/S as a tool for connection and deeper insight into a patient’s life is a strategy that places the CIT-S at the forefront of innovation driven by values of empathy, inclusion, and compassion.

Familial Units

 CIT-S regards family as an integral factor in obtaining and maintaining positive mental health among patients with schizophrenia. The authors encourage clinicians to draw on collectivistic family values of compassion and connectedness to form a network of support around the patient. This focus on unconditional support seeks to reassure patients that the support they receive from loved ones is not conditional on the course of their journey with schizophrenia. Rather, it stems from an unconditional familial anchor that remains firm through uncharted waters. While collectivistic familial mentalities are more common in minoritized networks, fostering principles of collectivism in treatment can be beneficial for minoritized and non-minoritized families alike. Throughout their discussion on familial support, the authors stay true to their DEI values and underscore the importance of acknowledging intersectionality while administering the CIT-S. Thus, through consistent reminders for clinicians to remain unbiased and non-judgmental, humility remains at the core of a clinician and patient’s shared journey through the CIT-S.

Research Based Protocol

For our poetic readers, CIT-S may be regarded as a story, beautifully articulating the ebbs and flows of life that may be utilized to promote patient and familial well-being. This 15-week “story” is separated into 5 modules that span 3 sessions each: 1) family collectivism, 2) psychoeducation, 3) spirituality, 4) communication training, and 5) problem-solving.

As opposed to comprehensively detailing these modules (which I encourage readers to obtain from CIT-S itself), I will instead explore nuances of self-reflection and cultural reverence that are ever-present throughout the manual. In CIT-S, the authors lay a foundation for how to handle conflicts in sessions while monitoring their own reactions to the situation at hand. This foundation is established through ground rules, and these rules are regarded as an imperative step toward preemptive conflict mitigation. Following the ground rules, subsequent modules in CIT-S are wrapped in elegant and clear prose that provides step-by-step clinical instruction. These instructions are divided by two parts: 1) General themes the authors encourage clinicians to interweave into their protocol execution styles (e.g., transcultural perspectives, celebration of cultures, and emphasis on connection) and 2) tailored goals for each module (e.g., questions to ask, potential module-specific obstacles, and information on overall module purpose). The beauty of this multi-faceted instruction is that is allows growth not solely for the patients and their families, but for the clinicians themselves. For instance, every module requires real-time adaptation to meet the unique needs of a patient, which allows clinicians the opportunity to expand upon the existing protocol and insert creative liberties where they see fit. Thus, while the authors present readers a structured, comprehensive protocol, they also allow the audience to write the protocol alongside them in real time to make the protocol their own. In a society built on pre-existing standards, CIT-S is a breath of fresh air for clinicians seeking to add their personal touch to our structured executions of clinical protocols. Accordingly, the authors state that throughout CIT-S they “discuss and promote beliefs and values that motivate clients to love and care for one another, even in difficult times⁵.” I implore clinicians to expand upon this thought and view CIT-S as a guide that allows them to expand their ownlove and care for clinical practice by embedding creativity into their work, even in difficult times.

Treatment Tools

“As for the future, it remains unwritten. Anything can happen, and often we are wrong. The best we can do with the future is prepare and save the possibilities of what can be done in the present.” (Todd Kashdan)⁶

This act of preparing for the present often requires the distribution of tools and skills to reach fruition. In CIT-S the authors provide just that in the form of handouts, homework assignments, case illustrations, and example role plays. In this provision, the authors once again illuminate their steadfast dedication to DEI, as every tool incorporates considerations for working with diverse identities. For example, case illustrations depict minoritized patients and families, and they encourage the consideration of factors unique to a patient’s cultural background. Similarly, role plays reference how and when to acknowledge culture in therapeutic settings, while handouts and homework assignments hone skills that celebrate protective factors that exist within one’s culture.

The handouts in particular are extremely helpful resources for clinicians moving forward with CIT-S. Nineteen handouts are provided for clinicians that cover treatment overviews for schizophrenia, instructions on how to embed culturally responsive care in therapy, and specific targets during therapy such as listening, communication, or emotion coping. Notably, the handouts highlight requests to “do something, rather than to stop doing something.” ⁵ This tactic skillfully thwarts inclinations to blame family members for their actions, and rather promotes change and growth from existing circumstances. Resembling the general protocol, the authors also leave room for clinician creativity in the presented tools. All materials provide a general structure for clinicians with the caveat that modifications should be made for unique patient cases. Overall, the addition of these resources adds to the spirit of the framework of the CIT-S, a protocol that rests on principles of genuine connection, compassion, and community through discourse.

Closing thoughts

The CIT-S is a protocol developed with the highest standards of intentionality and care seen in modern research. Through the CIT-S, the authors acknowledge that our complex societies require complex treatment solutions, and they provide just that through their protocol’s intersectional framework. I implore readers to also consider my plea that this protocol should not be a unique addition to psychological literature, but rather, should be the standard of care moving forward. Thus, future interventions should seek to disseminate similar culturally responsive protocols through various modalities, such as telehealth.

In sum, CIT-S provides clinicians a 60-minute clinical manual to treat patients with schizophrenia and support their familial units. However, I challenge our readers to take this one step further and consider an additional benefit that has not yet been addressed. Within those 60 minutes, the CIT-S allows you as a clinician to ingrain the following mantra within your practice: I root my practice in equity so that the “US’ in “U.S. (United States)” celebrates all our individualities that make this nation whole.

Discussion Questions

• What do you think about using principles of collectivistic (e.g., equality, collective interest, etc.) and individualistic (e.g., individual freedom, personal responsibility) societies in a therapeutic setting? Are there additional considerations clinicians should account for while using this approach?
• What are some dissemination tactics that could be used to distribute culturally responsive therapies? Are there various modalities (e.g., telehealth) that may also help bolster dissemination efforts?
• Discuss your thoughts on encouraging clinical creativity within clinical treatment protocols such as CIT-S. What are the pros and cons of allowing for this flexibility?
• Discuss your thoughts on the role of religion in therapy? What are ways you see nuanced and personal topics like religion adding to the overall effectiveness of the intervention?

About the Author

Nevita George, B.S. earned her degree in Psychology from Texas A&M University in 2019. After graduation, she worked as a clinical research coordinator at the Dauten Family Center for Bipolar Treatment Innovation at Massachusetts General Hospital. She is currently working as a research assistant at the Laboratory to Combat Human Trafficking (LCHT) in Denver, CO. Through her research, Nevita aims to uplift minoritized voices and tailor trauma-informed, survivor-centered care to meet the needs of BIPOC youth. Nevita is currently the co-chair for the graduate student arm of the Colorado Psychological Association (COPAGS) and is a student member of the American Psychological Association (APA) Div. 12’s (i.e., Society of Clinical Psychology) Diversity Committee.

References Cited