Often times the field of clinical psychology assumes a “deficit-based” approach to minority mental health. Consistent with the medical model that frequently drives assessment and case conceptualization, a deficit-based approach focuses attention on problem behaviors, “maladapted” adjustment, and psychopathology. Over-emphasizing deficits in minority mental health can be problematic for two central reasons. First, it can place more emphasis on the individual, rather than the systems of oppression, that contribute to mental health problems and unmet needs in ethnic and racial minorities. Attention to the individuals’ symptoms without considering context (e.g., daily experience of racism, generational trauma) can be misguided, stigmatizing, and invalidating for the patient and/or family presenting to treatment. Second, a deficit-based approach often directs attention away from the protective cultural strengths (e.g., strong sense of family, tireless resilience through hardship, sense of cultural pride) that an individual, family, or community holds. Consistent with previous work highlighting the importance of adopting a strengths-based framework for minority mental health (e.g., Gaylord-Harden et al., 2012), the focus on this blog post is to emphasize the benefits and practice of assessing and integrating cultural strengths into the treatment process for youth and their families.
The protective role of cultural identity
One protective factor that has been associated with positive outcomes in minority mental health is having a strong tie with one’s cultural background and/or racial or ethnic identity (e.g., Burnett-Zeigler et al., 2013; Yoon et al., 2013). For example, research on African American and Latinx adolescents has shown that having a strong sense of ethnic or racial identity can help buffer against the deleterious effects of discrimination and racism (Edwards & Romero, 2008; Sellers et al., 2006). Why? This can be understood through social identity theory (Tajfel, 1979), and the idea that feeling connected with a broader social group can enhance sense of self and self-esteem. By extension, having a strong tie to one’s cultural identity might also strengthen social support networks within families or communities of shared cultural background (Birman & Simon, 2013). Similar constructs (e.g., cultural socialization, or emphasizing cultural pride and heritage) have been identified as important treatment targets in interventions that were specifically designed with and for African American families (e.g., Anderson et al., 2018). Likewise, interventions for American Indian youth have found that incorporating cultural identity and cultural values have yielded improved outcomes (e.g., Morris et al. 2021). In addition to harnessing cultural identity to support youth, recent work by our team suggests that reaffirming cultural identity may also be an effective means of empowering cultural minority caregivers who are at high risk for stress associated with childrearing responsibility (Conroy et al., 2021).
What does it look like in clinical practice?
So, what are the take-home points for weaving cultural strengths in clinical practice? First, assessment is key. We recommend using psychometrically sound surveys (e.g., Multigroup Ethnic Identity measure—Revised, Brown et al., 2014) and/or interviews (e.g., Cultural Formulation Interview, APA, 2013; University of Connecticut Racial/Ethnic Stress and Trauma Survey, Williams et al., 2018) to inquire about families’ cultural identity at the outset of treatment (La Roche et al., 2020). Then, we recommend thoughtfully incorporating cultural identity into the case conceptualization and treatment process (for specific recommendations for family-based CBT, see Sanchez et al., 2021). Consider the following case example: a 12-year-old Hispanic girl, Rosa, presents to cognitive behavioral treatment for anxiety problems. Rosa specifically reports significant worries about her Spanish accent in her predominately English-speaking school (e.g., “my classmates think I talk in a weird way. I notice that they whisper to each other after I volunteer to read in class.”) In addition to validating how speaking multiple languages affects Rosa’s worries and is connected to experiences of discrimination and/or the minority stress that Rosa feels, a provider may ask: “what are the good things about being able to speak two languages? How has speaking both Spanish and English helped you?” Rosa responds and shares “it helps me talk to my grandparents and classmates at school. Overall, I guess I can understand and help more people.” The provider might validate and reflect this duality (e.g., an aspect of one’s cultural identity can relate to one’s distress and be a source of strength), “Speaking two languages sometimes makes you feel alone and different at school, and that is hurtful. It also helps you connect with your family, and with many more people around the globe. That’s a super cool and important gift you have.” The provider may then return to this strength (i.e., ability to connect with more people, and especially family members) as a means of empowering Rosa and promoting her identity development throughout treatment.
Lastly, it is important to note that the specific strengths and identities will vary based on the unique experiences of the individual, and therefore, assessment of cultural strengths is inherently a patient-centered process. Even two individuals who identify the same culture or country of origin (e.g., Hispanic) might have two very different experiences of that same culture or identity. Therefore, using mixed methods and open-ended probes along the lines of “Being Hispanic means different things to different people, what does it mean to you?” can help providers gain a more thorough and personalized understanding of individuals’ identity and cultural strengths.
Overall, the recommendation to incorporate cultural strengths into the treatment process must be understood in the broader pursuit of health equity, or the deep commitment to address (and eventually eliminate) the profound disparities documented in mental health outcomes across the lifespan (Braveman, 2014). While affirming and empowering individuals through their strengths and cultural identities has the potential to better elevate and engage individuals in mental health treatments, it is not sufficient for addressing the profound structural inequities in our healthcare system, nor the social determinants (e.g., factors related to systemic racism, location of living, quality of education, access to running water/electricity, access to affordable housing, immigration status) that continue to fuel disparities in care. Striving for equitable mental healthcare means both acknowledging and taking action to dismantle these structural inequities affecting the wellness of children and families.
- How can institutions and training programs better support clinicians in asking about cultural strengths and identity in the assessment and treatment process?
- For clinicians, how has increased national attention on racial stress and trauma influenced your clinical practice with youth of color?
- How does your own cultural identity interact with your practice of inquiring about patients’ cultural identity?
About the Authors
Kristina Conroy is a third-year doctoral student in the Clinical Science program at Florida International University (FIU) and a member of Dr. Jonathan Comer’s Mental Health Interventions and Technology (MINT) Laboratory. She completed her Bachelor of Arts (B.A.) degree in Psychology at Middlebury College and her Master of Science (M.S.) at Florida International University. Broadly, Kristina’s research and clinical interests revolve around supporting the existing efforts of the key adults (e.g., caregivers, teachers) with whom youth spend the most time. More specifically, Kristina is interested in infusing low-burden evidence-based practices for internalizing symptoms into youths’ natural settings, understanding the barriers and facilitators of implementing mental health supports in schools, and identifying culturally and contextually responsive anxiety supports for ethnic and racial minority youth. Kristina can be contacted at email@example.com.
Dr. Amanda Sanchez earned her PhD in Clinical Science at Florida International University. Her research and clinical interests center on improving access to quality mental healthcare for culturally diverse youth and families. More specifically, her work focuses on (1) understanding and addressing structural and systemic barriers to engagement, (2) delivering innovative mental health services in children’s natural environments, and (3) improving the cultural responsivity of mental health services and systems. In this vein, her work has focused on using cultural assessment to inform case conceptualization and treatment planning and identifying effective culturally responsive strategies that address specific cultural and contextual challenges (e.g., racism/discrimination, acculturation, housing/food insecurity) and cultural strengths (e.g., racial/ethnic identity, community support) within mental health treatment. As a graduate student, she led an NIH-funded project examining the use of the Cultural Formulation Interview as a strategy to improve satisfaction, engagement, and clinical outcomes among culturally diverse families. She is now a Postdoctoral Fellow at the University of Pennsylvania Perelman School of Medicine conducting community-partnered work to improve cultural responsiveness of community mental health services. Dr. Sanchez can be contacted at Amanda.firstname.lastname@example.org.
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