Anxiety fuelled by loneliness and self-doubt had such a grip on Sidra Mobin that she couldn’t get out of bed some days and took a leave from work. When the family she’d recently left in Pakistan called, she would keep her troubles in Canada to herself for fear of worrying them.
Mobin, 35, arrived in Burnaby, B.C., in June 2020. She didn’t know anyone and worked from home in a job that offered little challenge after a career as a management consultant in the bustling city of Karachi.
“There was a point where I really, really needed therapy,” said Mobin, who started seeing a therapist virtually nearly a year later but quit after three sessions because she felt no connection with the person trying to help her.
“I did not understand at that time why there was so much disconnect,” she said.
That would change after she learned in July 2021 about free cognitive behaviour therapy, or CBT, an evidence-based treatment based on modifying people’s negative thought patterns. It was being offered to people of South Asian origin as part of a study by the Toronto-based Centre for Addiction and Mental Health (CAMH).
The centre said that while South Asians have a higher rate of anxiety and mood disorders compared with the general population, they are 85 per cent less likely to seek treatment due to factors including socioeconomic disparities, cultural differences and stigma.
On Tuesday, CAMH offered therapists an online training manual on culturally adapted therapy specifically for people of South Asian origin.
The manual was developed after the study involving 146 participants, including Mobin, who were randomly assigned to receive eight to 12 sessions of either that model of therapy, or standard CBT from 29 specially trained therapists of various racial and ethnic backgrounds.
Weekly virtual sessions for three months were a turning point for Mobin because of a therapist who was aware of various aspects of her culture, including family dynamics, religious beliefs and something that turned out to be important – not asking inappropriate questions.
“He just understood everything. It was so validating,” Mobin said, adding she later learned her therapist had received training in culturally adapted CBT, or CaCBT.
He also did not make assumptions about the place of women in what Mobin called “moderately Muslim” Pakistan, she said.
“You might think that coming from a Muslim country, I might be suppressed or something like that, but I’m not. I had a very good life back home. I was very independent. I was doing everything that I do over here as well. And it did not come as a surprise to him.”
After participating in the study, she went to another therapist for what turned out to be a “disastrous experience” that lasted only one screening session of “inappropriate questions” about relationships, said Mobin, who now works for a non-profit that helps immigrants get back to the careers they had before arriving in Canada.
Dr. Farooq Naeem, a psychiatrist with CAMH and a pioneer in culturally adapted CBT, said the study was launched after researchers consulted members of the South Asian community, including those diagnosed with anxiety and depression and their families, to better understand the diverse population’s beliefs and experiences about mental health.
The results of the yet-to-be published study are still being analyzed. On average, participants in the study reported less than one visit to a psychiatrist in the six months following the end of treatment, compared with the standard CBT group, which had 1.5 visits during that time.
South Asians born in Canada showed more improvement in depressive symptoms, said Naeem, who is also a professor of psychiatry at the University of Toronto.
The findings of the small study suggest that adapting CBT to someone’s culture is feasible and further research with a larger sample size is needed to include factors such as acculturation and language barriers, he said.
Diversity among the South Asian population calls for the creation of best practices for health care in collaboration with the local community, he said.
While CBT has been a valuable intervention since its development in the United States in the 1970s, there has been a growing recognition that various cultural beliefs shape how people see things, said Naeem, whose South Asian roots are in Pakistan, Afghanistan and Iran. Therapists wanting to adapt CBT for that population or others should first be aware of their own biases, he added.
“I’m hoping that through this project people from other kinds of ethnic or racial backgrounds could also get culturally adapted therapy and services,” Naeem said.
Naeem does not believe people from a particular ethnic group should be matched with a therapist from their own background.
“I’ve been fighting against this whole idea because we don’t even have therapists for the main population. So how can I expect therapist-matching to work?”
“I do not agree with that and I think it’s a very dangerous idea. I think it’s very easy to train white or non-South Asian therapists so they can understand other cultures,” he said. “It’s my duty as a psychiatrist or a psychotherapist to understand your background. I don’t have an excuse.”
Helen Yohannes, a therapist in Ottawa, took part in the study and saw 28 clients of South Asian origin.
Having learned in her training from CAMH that family is a key consideration for South Asians allowed her to focus on that aspect, which helped people trust her more quickly, she said. Family members would sometimes attend sessions to better understand what was going on with their loved one.
“When there’s an issue, the whole family or community comes to try to fix it,” Yohannes said, adding that makes going to an outsider, including a therapist, challenging for people burdened with anxiety and/or depression.
The training she received also stresses spending more time discussing confidentiality so clients feel safe to divulge their personal issues, she said.
“Once I used it at my other job, I noticed how much it actually allows clients to open up and feel like ‘OK, I can talk about what’s going on without feeling like the person on the other end is going to judge right away or give me advice that’s not going to work with my religion or my culture,’ ” said Yohannes, who works with a federal program created during the pandemic to offer single-session therapy and other services for people across the country.
Culturally adapted CBT should be part of therapists’ initial education to allow them to connect with clients from various ethnic groups in an increasingly diverse country, she said.
“I think it’s definitely something that needs to be further explored, especially in schooling.”