Diverse and special populations

Transcript

RyanThe OpenStax psychology textbook introduces José. He's eighteen, Hispanic, from a traditional family, and he's come to treatment for depression. In the intake, he says he's gay, and nervous about telling his family. And his religious background has taught him that being gay is wrong.

SoheeThe textbook asks two questions. How does his religious and cultural background affect him? And how might it affect how his family reacts if he tells them?

RyanWelcome to EPPP Prep, the podcast. I'm Ryan.

SoheeI'm Sohee. Today's knowledge statement is about methods, and their evidence base, for prevention, intervention, and rehabilitation with diverse and special populations. It's three blueprint spots, and it touches almost every other episode.

RyanJosé's story comes from the textbook section on the sociocultural model. That perspective looks at you, your behaviors, and your symptoms in the context of your culture and background.

SoheeAnd it says mental health professionals must develop cultural competence. That means understanding and addressing issues of race, culture, and ethnicity, and developing strategies for populations where Eurocentric therapies have limited application.

RyanThe textbook's example, from Sue: a counselor whose treatment focuses on individual decision making may be ineffective with a Chinese client who has a collectivist approach to problem solving.

SoheeMulticultural counseling, as Sue described it, uses modalities and defines goals consistent with the client's life experiences and cultural values. And it balances individualism and collectivism in assessment, diagnosis, and treatment.

RyanNow the hard part: who actually gets care. The textbook says ethnic minorities tend to use mental health services less often than White, middle-class Americans.

SoheeAnd the obvious explanation, access, is only part of it. People report barriers like lack of insurance, transportation, and time. But researchers found that even when income and insurance are taken into account, ethnic minorities are far less likely to seek and use services. And when access is comparable, differences in use remain.

RyanSo the exam trap. An answer that says the gap disappears once insurance is equal. The textbook says the opposite.

SoheeAttitudes matter too. A study at King's College London found reasons people don't seek treatment: self-sufficiency, not seeing therapy as effective, confidentiality concerns, and stigma and shame.

RyanThe textbook also describes research where African Americans with depression were less willing to seek treatment because of fear of hospitalization and of the treatment itself. Many preferred self-reliance or spiritual practices, and the Black church has played a significant role in prevention and treatment-type programs.

SoheeAnd language. In a study of 462 Korean Americans over sixty, many reported depressive symptoms. Seventy-one percent said they thought depression was a sign of personal weakness. And there were no Korean-speaking mental health professionals where the study was done.

RyanSo, does adapting treatment to culture help? Here's the evidence. Bruce Wampold's review in World Psychiatry cites a meta-analysis of twenty-one studies. Adapting evidence-based treatments with an explanation that fits the cultural group's beliefs was more effective than unadapted treatment.

SoheeWith a qualifier: the effect was modest, d equals 0.32.

RyanAnd for self-help and digital treatments, a meta-analysis by Harper Shehadeh and colleagues looked at minimally guided interventions for depression and anxiety in culturally diverse groups. Eight trials. Higher cultural adaptation scores were significantly associated with larger effects.

SoheeThe most common adaptations were language translation and the use of metaphors. And they called for more research on how adaptation improves acceptability and effectiveness.

RyanOne more gap worth knowing. In episode three we heard Hofmann's review of CBT meta-analyses: apart from children and older adults, it found no meta-analyses of CBT for subgroups like ethnic minorities and low-income samples. So the evidence base itself has holes.

SoheePause and think. A psychologist plans standard individual CBT for a recently immigrated client who frames her distress as a family and spiritual matter. Based on these sources, what's the better move?

RyanIntegrate her cultural explanation into the treatment rationale and goals, and consider family involvement and her values, rather than dropping the evidence-based approach or delivering it unchanged. Wampold's finding is that the culturally congruent explanation is what helped, modestly.

SoheeLet's shift to trauma, because it cuts across every population. SAMHSA, the Substance Abuse and Mental Health Services Administration, describes what makes a program trauma-informed.

RyanIt realizes the widespread impact of trauma and understands potential paths to recovery. It recognizes the signs and symptoms of trauma in clients, families, staff, and others. It responds by integrating knowledge about trauma into policies, procedures, and practices. And it seeks to actively resist retraumatization.

SoheeRealize, recognize, respond, resist. And SAMHSA's principles include safety, peer support, trustworthiness and transparency, collaboration and mutuality, and empowerment, voice and choice.

RyanSAMHSA applies this to seclusion and restraint. Once seen as therapeutic, they are now viewed as traumatizing practices, to be used only as a last resort when less restrictive measures have failed and safety is at severe risk.

SoheeAnd it notes people who experience seclusion and restraint remain in care longer and are more likely to be readmitted.

RyanChildren next. The textbook says that when children are placed in group therapy, it is particularly important to match clients for age and problems.

SoheeAnd a safety point every child and adolescent clinician needs. NIMH says children, teenagers, and young adults under twenty-five may experience an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks or after a dose change. The Food and Drug Administration advises watching patients of all ages closely, especially early on.

RyanOlder adults. SAMHSA's guidance for older adults says changes to physical health can affect mental health and lead to substance misuse. It encourages people to talk with a doctor about mental health, drug, or alcohol issues the same way they would about physical health.

SoheeAnd SAMHSA treats practical barriers as real ones. It points to transportation help, like some Medicare Special Needs Plans, and Accountable Care Organizations that may offer free rides to some people on Medicare. It also reminds older adults that it's always a good time to get support, even after a lifetime of these issues.

RyanNow rehabilitation for serious mental illness. NIMH describes coordinated specialty care for first-episode psychosis. A team provides psychotherapy, medication, case management, employment and education services, and family education and support, making treatment decisions together with the person.

SoheeAssertive community treatment is designed for people with schizophrenia who are likely to have multiple hospitalizations or homelessness. A team delivers care in the community.

RyanAnd NIMH lists psychosocial treatments like cognitive behavioral therapy, behavioral skills training, supported employment, and cognitive remediation.

SoheeSupported employment has been tested in randomized trials. A meta-analysis by Frederick and VanderWeele in PLoS One looked at individual placement and support, the most popular version. People in it were more likely to obtain competitive employment, with a risk ratio of 1.63, and had longer job tenure and higher income.

RyanAnd the honest qualifier: for non-vocational outcomes like quality of life, global functioning, and mental health, the estimates favored the program but included the null. So it clearly helps people work. Whether it improves those broader outcomes is less certain.

SoheePause and think. A man with schizophrenia has been hospitalized four times this year and recently lost his housing. Which NIMH-described approach is designed for him?

RyanAssertive community treatment, built for people likely to have multiple hospitalizations or homelessness. Coordinated specialty care is the tempting distractor, but it's designed for first-episode psychosis.

SoheeLast population: people in the justice system. SAMHSA's Sequential Intercept Model details how people with mental and substance use disorders come into contact with and move through the criminal justice system.

RyanIt maps points where people can be diverted into treatment, from crisis services and law enforcement response, through jail and courts, to reentry and community supervision, so communities can find gaps and build local plans.

SoheeRecap. Cultural competence means understanding and addressing race, culture, and ethnicity, and adapting for populations where Eurocentric therapies fit poorly. Use gaps persist even when access is equal.

RyanCulturally adapted treatment showed a modest advantage, d of 0.32, in Wampold's review. For minimally guided treatments, more adaptation went with larger effects.

SoheeTrauma-informed care: realize, recognize, respond, resist retraumatization. Seclusion and restraint only as a last resort.

RyanMatch children's groups by age and problem, and monitor young people starting antidepressants. Address older adults' practical barriers. For serious mental illness: coordinated specialty care for first episodes, assertive community treatment for repeated hospitalization or homelessness, and individual placement and support for employment.

SoheeEveryone who studies for this exam brings their own culture and story into the room. Yours is an asset, not an obstacle. It's part of what will make you good at this work.

RyanThanks for listening to EPPP Prep.

Loading the read-along timings…