Health

Race, Religion and Mental Health: Why Therapy Should Be Culturally Relevant

Mental health care urgently needs to be more adaptive to the needs of different communities. What’s available now is often unhelpful, insensitive or worse.

Years ago, when Rod McCormick was teaching psychiatrists-in-training at the now-defunct Riverview Hospital in Coquitlam, B.C., he suggested a healing technique that wasn’t in his students’ textbooks.

McCormick, a psychologist and professor whose career has centred on counselling and Indigenous mental health, asked a group of interns what they did for their own healing. All the examples they gave shared a common thread: reconnecting with nature.

“Do you use that for your own patients?” asked McCormick, who is a part of the Kanien’kehá:ka (Mohawk) Nation and the director of All My Relations, a research centre aimed at advancing Indigenous wellness at Thompson Rivers University in Kamloops, B.C. The interns told him they didn’t, while admitting their current techniques weren’t working very well.

So McCormick offered up an alternative. Riverview was a psychiatric hospital located on some of the most beautiful grounds in the Lower Mainland, an idyllic location. McCormick knew local elders who would be willing to join the group in the surrounding forests to explain how to use trees, rocks, water and sky in their healing. The interns were excited—they thought it was a great idea. But the plan never came to fruition.

“I guess somebody higher up thought, ‘That’s silly. That’s not the medical model,’ ” says McCormick. He has plenty to say about the medical model, though, including who it was created for. “I’ve trained psychologists and counsellors for about 25 years now,” he says. “I always remind them that all those theories and interventions they learn come out of textbooks, and they’re all based on a European-Western world view.”

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The term “mental health” usually invokes psychology, and Europeans lay claim to its modern formulation: Its early growth and foundational research was focused on a homogeneous demographic, one that was entirely white (and, usually, male, able-bodied and heterosexual). Its frameworks were derived from Euro-Western conceptions of the human experience, and its implementation has largely suited that same population. But psychology’s roots extend far past the 19th century, and wider methods of approaching good mental health—drawn from ancient civilizations, religious communities and other populations—often go unconsidered.

Today, the inattention to other cultures, races and religions is palpable when considering access to mental health care in Canada and the effectiveness of the treatment that patients receive. In such a diverse society, it’s been clear for a while that culturally specific modes of therapy are an urgent necessity. Progress has been slow, stalled by pushback and a lack of research or funding. But in recent years, a few innovative frameworks have emerged to successfully treat the mental health needs of various communities and individuals.

Sometimes, it’s possible to adapt existing treatment models to suit particular communities. Farooq Naeem, the chief of general and health systems psychiatry at the Centre for Addiction and Mental Health (CAMH) in Toronto, pioneered techniques for adapting cognitive behavioural therapy (CBT) for South Asian patients. One of the most popular forms of therapy today, CBT is typically a structured, short-term form of psychotherapy that focuses on the here and now. It helps patients analyze how their thoughts affect their feelings, and how those feelings affect their behaviours. Naeem’s adapted model retains the basic techniques of CBT, while adjusting certain language, and taking culture and religion into consideration. He found that behavioural and problem solving techniques were more acceptable to South Asians than other CBT tactics, and a more directive approach was more effective than a collaborative one.

The CAMH adaptation process expanded to encompass other cultures and identities, and in 2009, psychologist Natasha Williams was approached to help adapt CBT for English-speaking Black Canadians with roots in Africa and the Caribbean. Black people are particularly neglected by the current system—on average, they wait 16 months for provincially funded mental health treatment, which is double the already-long average of eight months.

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Again, language was one of the first problems Williams’ team noticed during the adaptation process: The Western diagnostic manual being used prevented practitioners from recognizing specific terms that African or Caribbean Canadians might use when expressing mental health-related symptoms. “Somebody may not say they’re ‘sad,’ but they may be ‘vexed.’ Not understanding what that means in this context…it can be pushed aside and not seen as a possible criteria for depression,” says Williams.

Also important in mainstream CBT is the concept of “core beliefs,” or absolute notions of oneself learned through childhood experiences, parenting and overall environment. Those need to be understood through a culturally aware lens, as well.

“Colonialism…, racism [and] transgenerational trauma, those types of things had to be part of the conversation to fully understand somebody’s core beliefs,” says Williams. “In traditional CBT, those things typically are not explored.”

In such a diverse society, it’s clear that culturally specific modes of therapy are an urgent necessity

Then there’s the issue of who’s administering the therapy. Williams’ pilot program and the manual that followed only included input from Black clinicians, an approach that was rewarded when several participants indicated they had trouble opening up to white therapists. “They feel that [they’re] speaking to their colonizer: ‘How can the person that oppressed me actually aim to heal me?’ ” Williams explains.

Marian is a Black Muslim woman living in Ottawa. Finding therapists who can understand the intersections of her identity has been difficult—she’s been trying for a year, and she’s hesitant to consider a white therapist. “For Black folks, or Black Muslim folks, we’re always living in an existence of trying to explain every part of our identity or validate [our] experiences to people,” she says. “It’s already hard enough.”

Williams says that while clinicians and patients don’t necessarily always have to be the same race or ethnicity, there does need to be an exploration of the dynamic between therapist and racialized clients if the clinician is white. And the feedback from the adapted CBT model has been heartwarming. Participants reported increased social interaction, decrease in depressive moods and a reduction in shame or stigma previously associated with mental health care, particularly those who went through group therapy.

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The failure to address systemic racism, bias and colonization in traditional CBT is a microcosm of the issues that plague mental health care generally. It demonstrates how Indigenous, Black and communities of colour are often left out when it comes to developing models of care. Too many racialized people end up in therapy situations in which they don’t feel safe exploring issues pertinent to their lived experience.

“It’s a systemic issue. There’s just so much that needs to be done,” says Williams. Funding is always an issue, although important acknowledgements have been made: In 2018, the federal government committed $19 million over five years to mental health programs in Black communities.

But cultural insensitivity is still a barrier and, Williams says, it can lead to a reluctance to go to psychotherapy at all. That reluctance is often justified. Black youth are four times more likely to enter the mental health system through hospital emergency departments than white youth—and 2020 has shown just how dangerous emergency mental health situations can be for Black, Indigenous and other racialized people.

Between April and June of this year, six racialized Canadians died during police interactions instigated by their mental health emergencies. That includes 62-year-old father of four Ejaz Choudry, who was shot by police while experiencing a schizophrenic episode in his Mississauga, Ont., home in June.

According to psychiatrist Yusra Ahmad, “there was such a lack of any attempt to even understand the root of [Choudry’s] distress”—his family had called for paramedics, not police. “Fear of being judged and misunderstood is so profound that the last thing you’d want to do is trust a system that has not even taken you into consideration and doesn’t really want to.”

Ahmad, who is also a clinical lecturer at the University of Toronto, has spent years devising new approaches to treating Muslim patients. “A lot of mindfulness programs profess to be holistic, [but] there is an uncanny discomfort with issues of the spirit,” she says. “I know just how valuable faith and spirituality is to many people…and yet these were rarely addressed, if at all, in meaningful ways by the psychiatric establishment.”

In 2017, Ahmad started Mindfully Muslim, a 10-week group therapy program for Muslim women with anxiety or depression that combines mindfulness-based cognitive therapy (MBCT), mindfulness-based stress reduction and mind-body work with Islamic wisdom. At the centre of the program is the poem “The Guest House,” by 13th-century Persian poet and scholar Rumi, which calls for compassionately receiving whatever life brings, accepting every feeling and experience as a guest to the soul: “Be grateful for whatever comes/Because each has been sent as a guide from beyond.”

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The poem is actually part of the official MBCT model used worldwide, but non-Muslim practitioners usually aren’t taught its spiritual connotations. “Many presentations of Rumi are highly decontextualized,” Ahmad says. “The fact that he was an erudite Islamic scholar and [memorized the] Quran seems to have been set aside.”

Muslim participants and community organizations have embraced Mindfully Muslim, but Ahmad says that her peers have had mixed reactions. Some were very supportive, nominating her for the Ontario Psychiatric Association’s Breakout Community Psychiatry Advocacy Award—which she won last year. But other colleagues simply ignored her faith-based perspective when she first proposed the project, and some straight-out said that her “emphasis on faith was cringeworthy.”

Ahmad believes this hesitancy comes from a general discomfort with faith traditions, as well as negative stereotypes of Islam that have engendered fear and ignorance. “It only emboldened me to continue chipping away, because if I was experiencing that as a mental health professional, as a psychiatrist from my own colleagues, imagine what it’s like for a patient,” she says.

a one-size-fits-all mode of therapy too often fails communities who need help the most

A one-size-fits-all mode of therapy too often fails communities who need help the most

For Salma Hindy, who works in biomedical engineering and is also a stand-up comedian in Toronto, the pursuit of mental health care that acknowledges her experience as a Muslim woman has meant seeing multiple therapists at the same time.

Her first and long-standing therapist is agnostic, and while they clicked on the more textbook aspects of therapy and psychology, she felt judgment with regards to her faith early on. Like Marian in Ottawa, she feels that having to explain religious practices and modes of thinking on top of issues like depression and anxiety can be exhausting.

“I felt like I had to almost defend my religion. I felt like I was on trial,” she says. While the two were able to build a rapport over time, Hindy says that her therapist still won’t touch issues that centre around religion.

For Hindy, an integrated framework of spirituality and psychology has meant building a personal roster, with a medical mental health professional on one end and an imam, or Muslim religious leader, who can speak to her spiritual struggles on the other. Putting it all together took up a lot of time.

In Kamloops, McCormick has also found Western views on spirituality problematic. “I grew up in Catholic schools, and the world was sort of like a triangle: on top was God, in the middle was humans, at the bottom was nature,” he says. “[In] an Indigenous cosmology, you got three points on the circle: God, human and nature. It’s not hierarchical, and it’s not compartmentalized.”

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The Western model wouldn’t necessarily look to God or spirituality for healing, he says, and it certainly wouldn’t turn to nature, which is seen as below humans. “Whereas, in an Indigenous world view, you would look to both sources for healing because they’re all part of creation, equal to humans,” says McCormick.

His “Healing from the Land” course did eventually come to fruition: He taught alongside local elders and traditional knowledge holders, and classes often started by piling into a bus and heading straight into nature.

The course was popular, and more than half of the students present were Indigenous. Day one was trees and forests, then rivers, then lakes and water, then earth and plants, and finally, hills and mountains on the fifth day.

“They learn things like how nature can be grounding, connecting…how it can be calming, how nature can provide perspective and guidance, and be empowering,” says McCormick.

To explain its success, the psychologist considers a theory put forth in 1946 by Jewish psychiatrist Viktor Frankl, a Holocaust survivor. “He said that individuals and cultures can survive if they have a strong reason for living,” says McCormick, noting reasons such as spirituality, work, relationships and contributing to one’s culture or community. “The process of colonization for Indigenous people was to separate us from those sources of meaning.”

When McCormick was researching suicide, for example, many of his participants (who had been suicidal in the past) expressed a desire to reconnect to their cultures and communities. “Five out of the 25 interviewed mentioned getting an Indian name, a traditional name,” McCormick says. So he explored naming ceremonies on the west coast of B.C.: Often, part of the tradition is having the community present to hear the family describe those who have had that name in the past, what the name means, and the teachings and responsibilities that come with it.

In many communities, such names mark different stages in a person’s life. But treatment centres where such ceremonies are possible are rare, and McCormick says they often aren’t equipped to help participants reintegrate with their everyday lives and community afterward—which is of utmost importance to the naming ceremony. Further exploration of these ideas has been difficult, given both the lack of resources and general discomfort with integrating spirituality into the existing mental health framework.

It’s clear there’s a long way to go to make mental health care more relevant and accessible. The barriers are many, from Eurocentric curricula and teaching methods, to the social determinants of health that make racialized people more likely to experience mental distress, to the financial barriers that make it difficult for many people to access treatment at all.

Ahmad shares the hope that more people will come forward who are willing to think creatively and push the boundaries of what’s possible. “The culture is not as supportive as it needs to be,” she says. “It’s changing pretty rapidly at certain levels, but whether it permeates at all levels, we have yet to see.”

Clearly, a one-size-fits-all mode of therapy too often fails communities who need help the most—in worst-case scenarios, its oversights can be catastrophic. Openness and evolution are needed to give medicine its best chance at doing what it was created for: healing people.

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