Special edition of Psychology and Psychotherapy: Building an Integrative Science of Psychotherapy

for the 21st-Century

Psychology across cultures: Challenges and opportunities

Author

Dr Dawn Edge PhD, MRes, BSc (Hons) 1, 2

Senior Lecturer/Associate Professor

Dr Henna Lemetyinen PhD, BSc (Hons) 1

Senior Research Assistant

Affiliations

1. Division of Psychology & Mental Health

School of Health Sciences

Faculty of Biology, Medicine & Health

The University of Manchester

Oxford Road

M13 9PL

Email: dawn.edge@manchester.ac.uk

Tel: +44 (0) 161 275 2570

2. Research & Innovation

Greater Manchester Mental Health NHS Trust

Bury New Road, Prestwich, Manchester, Greater Manchester, M25 3BL

Abstract

Large variations of and inequalities in rates of mental health disorders, and access to mental

healthcare exist within and between countries. Globally, disparities range from countries where

there is little provision to those where, despite the availability of evidence-based mental healthcare,

service access and outcomes are mediated by social factors such as socio-economic status,

race/ethnicity and culture. This is salient because increasingly diverse populations are inevitably

created with globalisation. We posit that, in multi-cultural contexts, effective therapeutic

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engagement requires therapists who are competent and confident to work with diversity and

difference; utilising insights into their own as well as their clients’ internal and external worlds.

Although there are many reasons why psychotherapies can be insensitive and harmful, e.g. the

inherent power imbalance in therapeutic relationships, a lack of awareness of cultural and ethnic

variation and needs are amongst them.

Acquisition of ‘cultural competence’ and increasing availability of culturally-adapted interventions

should, in theory, enable practitioners to work with a range of individuals with whom they might

have little in common. However, whilst cultural-adaptation appears promising, there are concerns

regarding its viability as a strategy for tackling disparities in access to psychological care. Evidence

for cultural competency is patchy at best. We show how and why delivering effective psychotherapy

in the twenty-first century requires a paradigm shift from current approaches to truly integrated

models, developed in collaboration with recipients of care. Co-producing interventions, training, and

means of evaluating them with clients necessitates taking into consideration social contexts,

alternative conceptualisations of mental health and disorders and difficulties and what constitutes

appropriate helpful interventions for psychological distress.

Key words: Ethnicity, culture, disparities, psychological care, cultural-adaptation, global mental

health, cultural competence

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Psychology across cultures: Challenges and opportunities

Introduction

Though ill-defined (Fernando, 2012) and the subject of polarised debate (Bemme & D'Souza N,

2014), the concept of ‘global mental health’ (GMH) has gained increasing salience in recent decades.

The term is generally used to signify that mental health difficulties transcend geographical

boundaries and are inextricably linked to social contexts and cultures (Bemme & D’souza, 2014; Das

& Rao, 2012). GMH imputes the interdependence of high, middle- and low-income countries,

acknowledging that unequal distribution of wealth and other resources including access to mental

healthcare is one of the consequences of globalisation (Kirmayer & Pedersen, 2014). This approach

explicitly acknowledges that social determinants of mental health are rooted in socio-economic and

historical contexts and that responses to suffering are embedded in ethno-cultural systems of

meaning and healing that are part of the religious, spiritual, and moral fabric of communities and

societies (Fernando, 2014). In contrast to predecessor terms such as ‘tropical medicine’ and

‘international health’, global health emphasises the centrality of building local capacity for

addressing disparities versus importing medically-based models of disease prevention and

interventions that are almost always entirely grounded in Western traditions (Kirmayer & Pedersen,

2014). For proponents of global mental health, replicating and scaling up evidence based models to

improve access to care in countries with few resources is integral to eradicating global inequalities in

provision and outcomes (World Health Organization, 2008).

There is inherent tension in this perspective – for example, what counts as evidence and the validity

of such models across contexts and cultures. Whereas people in low and middle income countries

(LAMICs) are usually the subjects of global mental health research, studies predominantly emanate

from individuals and organisations in high income countries (HICs) – specifically, North America,

Europe and Australasia (Das & Rao, 2012). Accordingly, much of current discourse, on symptom

patterns, syndromes and clusters, evidence for the incidence and prevalence of mental health

difficulties, and psychosocial interventions to address them, are grounded in Western approaches.

These rarely acknowledge the effect of social and cultural factors on what is labelled ‘mental illness’,

the labelling process, and the range of potential options for responding to such experiences

(Fernando, 2014; Tseng, 2005). Even the language of ‘illness’ is problematic since many forms of

mental health difficulties and forms of suffering can be ‘normal’ responses to toxic environments

(Gilbert, this volume).

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Further, as the ways in which psychological problems are categorised and counted utilise Western-

centric systems of psychiatric nosology, this calls into question the legitimacy of some

epidemiological data, especially when these are agglomerated. To illustrate, the global prevalence of

depression during pregnancy and the early postpartum period is routinely quoted as 15% (O'Hara &

Swain, 1996). However, this obfuscates both inter- and intra-ethnic differences. Research among

Israeli Arab women, for example, reported significantly higher rates of depressive symptoms in early

motherhood among Moslem compared with Druze women (19.0% vs. 13.4% (p = 0.01) but

considerably lower than among Arab Bedouin women (43% at the EPDS ≥10 and 26% ≥13) in

southern Israel; implicating the role of socio-cultural factors (Glasser et al., 2012 ). More recently,

although a qualitative study across 15 centres in 11 countries found evidence to support the

universality of morbid unhappiness among new mothers (Oates et al., 2018), the findings

underscored previous concerns about the utility and cross-cultural equivalence of psychiatric

concepts (Edge & MacKian, 2010; Hickling, Gibson, & Hutchinson, 2013; Zafar et al., 2008) . Although

diagnostic constructs and epidemiological studies enable evaluation of population need; they can

also hide the role of social determinants of mental health and hinder development of alternatives to

current interventions and ways of working.

Mental health and illness in a global context

Whilst biological and psychological factors contribute to the aetiology of mental disorder and

difficulties, putative risk factors such as genetic predisposition and psychological vulnerability do not

account for differential rates between groups (Hutchinson & Haasen, 2004; Hutchinson et al., 1996;

Jablensky, 2000). Research consistently implicates socio-economic disadvantage, lack of social

capital, unavailability or poor quality of social support, and experiencing discrimination,

marginalisation and stigma in onset and maintenance of mental health difficulties (Allardyce,

Gilmour, Atkinson, Rapson, Bishop & McCreadie, 2005; Eliacin, 2013; Kirkbride et al., 2007; Morgan

et al., 2008). There is also considerable evidence that social factors have epigenetic effects making

the social and biological intimately connected (see Kumsta, this volume).There is also evidence that

different illness models and cultural expression can contribute to under-diagnosis, misdiagnosis,

and/or over-diagnosis (Adams et al., 2015; Dowrick et al., 2009); leading the UK’s Royal College of

Psychiatrists to formally acknowledge the inter-relationship between discrimination and institutional

racism on both diagnostic categories and rates of mental illness (Royal College of Psychiatrists,

2018). One area where this is most evident is in consistent reports of elevated rates of schizophrenia

diagnosis among Black people in predominantly White societies. For example, in the UK, Black

Africans and Caribbeans’ likelihood of receiving a schizophrenia diagnosis is respectively six and nine

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times greater than of white British people (Morgan et al., 2006). Over-representation of

schizophrenia diagnoses in African Americans men has generated observations about use of the

diagnostic category as a mechanism of social control (Metzl, 2009).

Inequalities extend beyond diagnosis to service access, experiences and outcomes. Globally, there is

a significant gap between the number of people in need of mental health help and support and

those who receive it. This ‘treatment gap’ is greatest in LAMICs, ranging from 76.3% to 85.4%, which

accounts for between 8.8% and 16.6% of the total disease burden in these countries (World Health

Organization, 2004). Specific to severe mental disorders, it has been estimated that the percentage

of untreated individuals is closer to 100% (Betancourt & Chambers, 2016). Among the preeminent

challenges LAMICs face in meeting the mental health needs of their populations are lack of resources

(including trained professionals), structural and organisational barriers (such as lack of infrastructure

to enable service delivery and/or accurate data collection), absent/inadequate mental health

legislation, and unavailability of evidence-based treatments (Rathod et al., 2017).

Disparities in mental healthcare also exist in high income countries (HICs). Significant differences in

risk and prevalence of mental health difficulties have been reported between people of colour not

just in predominantly White but also in multi-cultural societies; further mediated by intersections

with other factors such as gender and socio-economic status (Bhui & Bhugra, 2002; Breslau, Kendler,

Su, Gaxiola-Aguilar, & Kessler, 2005; Morgan et al., 2005). In this context, it has been noted that high

density of specialist provision does not result in uptake of services commensurate with the levels of

morbidity among some groups. This suggests that increasing specialist interventions might not

reduce disparities in access to mental healthcare without targeted interventions to improve

initiation of help-seeking and service engagement (Cook, Zuvekas, Chen, Progovac, & Lincoln, 2017).

Stigma is one of the most commonly-reported barriers to help-seeking (Corrigan, 2004; Kollmann,

Amering, Schrank, & Sibitz, 2011; Morant et al., 2011; Parcesepe & Cabassa, 2013; Vogel, Wade, &

Hackler, 2007; Wood et al., 2014). Although stigma against mental health problems exists in all

communities, there is evidence indicating particularly high levels in minority communities with

associated negative effect on help-seeking and treatment initiation (Alvidrez, Snowden, & Kaiser,

2008; Arthur et al., 2010; Edge & Rogers, 2005; Shefer et al., 2013; Sorkin, Murphy, Nguyen, &

Biegler, 2016; Thornicroft, Deb, & Henderson, 2016). Internalized stigma has been found to be

particularly detrimental to help-seeking (Livingston & Boyd, 2010; Morrison et al., 2014; Pyle et al.,

2013; Ritsher, Otilingam, & Grajales, 2003). Despite this awareness, interventions to reduce stigma,

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especially as a means of improving service engagement, have had little impact (Brohan, Elgie,

Sartorius, & Thornicroft, 2010; Knifton, 2012; Mehta et al., 2015).

Additional barriers to seeking and receiving help from statutory services include factors that trigger

help-seeking and interactions between clients and health providers. These encompass how service

users, their families and wider social networks conceptualise mental health difficulties, their beliefs

about what constitutes valid interventions, and how service providers interpret clients’ experiences

and expressions of distress. It has been theorized that societies function by operating systems of

residual rules that determine whether or not behaviours are socially-sanctioned (Scheff & Brown,

2002). Lower status individuals and those identified as ‘outsiders’ are more likely than high status

‘insiders’ to be regarded as ‘mentally ill’ or deviant when their behaviours transgress these rules

(Metzl, 2009). In high income countries, individuals from ethnic minorities disproportionately occupy

low status, low power positions; increasing their vulnerability to mental ill-health and the risk of

expressions of psychological distress in responses to adversity being medicalised, criminalised or

both (Cermele, Daniels, & Anderson, 2001; Rogers, May, & Oliver, 2001). Consistently, high rates of

schizophrenia diagnosis among Black people in the UK coupled with police involvement and use of

the Mental Health Act (HM Government, 2007) in their care pathways serve as an example of the

confluence of psychiatry and criminal justice systems to manage distress in an ‘outsider’ group

(Lawlor, Johnson, Cole, & Howard, 2012; Morgan, Mallett, Hutchinson, & Leff, 2004; Mukadam,

Cooper, & Livingston, 2011). This response is by no means universal. In contrast to Black men, who

are stereotyped as being "out of control" and ‘Big-Black-and-dangerous’ (Ferguson 1993), South

Asian women are seen as passive and "private and too controlled" (Littlewood, 2001), resulting in

high rates of diagnosis with pregnancy-related depression that coincide with women’s interaction

with statutory services.

In relation to illness models, members of ethnic minority groups frequently cite discrimination as

both a trigger for mental illness and barrier to receiving effective care (Bhui, Halvorsrud, & Nazroo,

2018; Jimenez, Bartels, Cardenas, & Alegría, 2013; Memon et al., 2016). Racism is associated with a

two-fold increased risk of psychosis among African-Caribbean people (Karlsen, Nazroo, McKenzie,

Bhui, & Weich, 2005) and inferior outcome of mental healthcare (Priest, Paradies, Trennerry,

Truong, Karlsen, & Kelly, 2013). Experiencing racism or discrimination is also associated with low

rates of treatment satisfaction (Benkert, Peters, Clark, Keves-Foster, & Detroit, 2006) and perceived

poor quality of care (Sorkin, Ngo-Metzger, & De Alba, 2010). However, practitioners are often

unaware of these experiences or how they contribute to ethnically-based disparities in care

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(Mallinger & Lamberti, 2010). Service users’ perception that practitioners disbelieve and/or

pathologise their experiences of racism and discrimination, especially within services, contributes to

mistrust (Armstrong et al., 2013; Benkert et al., 2006; Edge et al., 2018), non-adherence and

disengagement (Neighbors et al., 2007; Whaley, 2001).

Psychology and psychotherapy in multi-cultural societies

Although formalised, the process by which practitioners interpret clients’ expressions of distress to

make diagnoses and clinical decisions relies to a large extent on social interactions that occur within

a wider social context (Littlewood, 2001). From a social construction perspective, what counts as

‘mental illness’ is negotiated during the diagnostic process within a wider social context (Rogers et

al., 2001). What is regarded as mental illness (or not) is therefore neither constant nor fixed but

evolves under the influenced of socio-political and other factors (Metzl, 2009) as evidenced in

changes to Diagnostic and Statistical Manual (DSM) (American Psychiatric Association, 2013) and

International Classification of Diseases (ICD) (WHO, 2018).

However, it is rarely acknowledged that in the process of diagnosis/case formulation both

practitioners (generally powerful members of the dominant culture) and clients have ‘culture-bound’

ways of making sense of what comes to be labelled as symptoms of mental illness (Lipsedge &

Littlewood, 2006). Research has shown that practitioners may be unaware of the extent to which the

social distance between themselves and their clients affects therapeutic engagement and alliance

(Fung & Lo, 2012). They also appear to be unaware of the extent to which practitioners’ (often

unconscious) biases and prejudices contribute to health disparities (Drewniak, Krones, & Wild,

2017). A systematic review of practitioners’ views on White Americans and BAME populations

provides an account of how implicit bias and stereotyping negatively affect provider-patient

relationships, treatment adherence, clinical decisions and health outcomes (Hall et al., 2015).

Cultural competency training has been suggested as a means of increasing practitioners’ awareness

of the social contexts in which their clients experience psychologic difficulties as well as their own

responses to improve clients’ engagement, experience, and outcomes by improving their ability to

work cross-culturally (Thompson, Bazile, & Akbar, 2004). In contrast to cultural

sensitivity/awareness, which merely affords insights into cultural beliefs and experiences, cultural

competence can be defined as the ability to understand and respond appropriately and effectively to

other people’s cultural needs, establishing interpersonal relationships to bridge differences

(Mallinger & Lamberti, 2010).

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This is important because societies are increasingly multi-ethnic and multi-cultural. Practitioners

largely trained in Western biopsychosocial models of mental illness, rarely receive training that

equips them to work with diversity and difference. These models are best understood within a

framework comprising biological factors (e.g. genes), psychological factors (e.g. behaviour) and

social factors (e.g. socio-economic status) (Engel, 1977), with no factor having priority in explaining

aetiology of illness or treatment approaches (Deacon, 2013). More recent developments to these

approaches are outlined by Siegel, (this volume) and Gilbert (this volume) who argue that our

understanding of the sources of mental health difficulties and ways to be helpful rest on a better

understanding of basic human needs (e.g., for care, support, belonging, connectedness, freedom

from fear, respect). These frameworks give rise to the emergence of cross-disciplinary mental

healthcare and research, allowing professionals to adopt non-reductionist perspectives on wellbeing,

healthcare provision, and research (Babalola, Noel, & White, 2017) as embodied in World Health

Organization's (1948) definition of health.

Despite the model’s undeniable theoretical merits, the significance of its practical applications is less

evident. In practice, health professionals’ negative attitudes to the importance of psychosocial

issues remain intractable barriers to full implementation of the model (Astin, Soeken, Sierpina,

Clarridge, 2006). In addition, they have been criticised for omitting spirituality despite evidence that

only 10% of the world’s population is unaffiliated with religious beliefs, practices or communities

(Maoz & Henderson, 2013). Health professionals can regard spiritual matters as irrelevant, harmful

or even pathological; restricting the potential for understanding service users’ states of mind. In

addition, it closes down options for working collaboratively with a wider range of individuals such as

spiritual leaders and traditional healers (Burns, Jhazbhay, Kidd, & Emsley, 2011) to provide truly

holistic care (Koenig, 2012; Pargament & Lomax, 2013).

Spirituality is just one area where there is lack of congruence between service users’ and

professionals’ perceptions of the causes and appropriate responses to psychological difficulties,

which clearly has implications for therapeutic engagement and outcomes (Koenig, 2012). Culturally-

specific beliefs and explanatory models about mental health and illness have been widely

documented (Abdullah & Brown, 2011; Bhui & Dinos, 2008). Generally the beliefs of people from

Western, ‘individualistic’ cultures are contrasted with non-Western, ‘collectivist’ cultures; typically

African-centric and Asian, (Angermeyer & Dietrich, 2006; McCabe & Priebe, 2004). However, service

users’ illness models and treatment preferences indicate considerable cross-cultural variation. For

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example, people of African and/or Caribbean heritage are more likely to endorse faith-based or

spiritual treatments compared to Whites (Jimenez, Bartels, Cardenas, Daliwal, & Alegría, 2012;

Nadeem, Lange, & Miranda, 2008). People of Chinese heritage are more likely to use complementary

and alternative medication, such as herbal remedies, than other ethnic groups in the UK (Hunt et al.,

2010). South Asian peoples tend to use traditional healing methods, such as worship and spiritual

readings (Chiu, Ganesan, Clark, & Morrow, 2005), often in conjunction with Western psychiatric

practices (Dein & Sembhi, 2001).

Towards solutions-focused approaches

i) Improving interaction and engagement: A notable achievement of the biopsychosocial

model is the ability to incorporate the practitioner-patient relationship into understanding

service user/patient outcomes. Using computer simulations, doctors with a higher patient-

centered (HPC) communication style (HPC) compared to a low patient-centered (LPC)

communication style, African-Caribbean people feel more comfortable disclosing emotional

state, when doctor is using HPC style. The doctor’s race or ethnic background (being Black or

White) did not impact disclosure. Additionally, compared to White British people, Black

people were more willing to accept therapy when doctor used HPC compared to LPC (Adams

et al., 2015). These are supported by qualitative findings indicating that patients wanted

empathic and respectful health care providers that heard and understood them to facilitate

more comfortable relationships (King et al., 2015).

ii) Cultural competency: One of the most commonly suggested solutions to addressing the

effect of implicit bias and prejudice in healthcare is cultural competence training (Beach et

al., 2005). Ninety-six percent of postgraduate (resident) physicians across different medical

disciplines in the US consider cultural issues as ‘moderately important’ or ‘very important’ in

health care (Weissman et al., 2005). Training programmes for health professionals typically

consist of educating participants in the epidemiology of illnesses in ethnic groups and

cultural theories such as ethnorelativism (Price et al., 2005). Programmes may also include

increasing awareness of interpretation and translation services (Anderson, Scrimshaw,

Fullilove, Fielding, & Normand, 2003; D’Ardenne, Ruaro, Cestari, Fakhoury, & Priebe, 2007),

how to adapt communication styles (Teal & Street, 2009), and incorporating culturally-

specific beliefs, values and explanatory models of mental health disorders (Kleinman &

Benson, 2006; Hodge & Nadir, 2008). Low-to-moderate evidence suggests that cultural

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competence training has potential to improve service user outcomes (Horvat, Horey,

Romios, & Kis-Rigo, 2014).

However, despite numerous training programs, evidence for their effectiveness lacks rigour.

A systematic review by Price et al. (2005) on the quality of methodologies evaluating cultural

competence training programs reported that only two out of 59 studies were randomised

controlled trials (RCT). The majority of the studies evaluated health professional outcomes

with only four studies measuring patient outcomes, none of which included health

outcomes. Another review (Horvat et al., 2014) of the effectiveness of cultural competence

training identified five RCTs evaluating such training. Findings were mixed, showing some

evidence of increased patient satisfaction with consultations, improved mutual

understanding between patients and professionals, and appointment attendance

concordance. However, the review found no evidence for improved treatment outcomes, no

study assessed adverse outcomes and no study evaluated the impact of cultural competence

training at an organisational level. In summary, whilst inreasing practitioners’ cultural

competence has the potential to improve service user engagement, experience and

outcomes, implementation and evaluation are hindered by lack of consensus on what

constitutes cultural competence, how related training should be delivered and assessed

both at practitioner and organisational levels.

iii) Culturally-adapted interventions: Acknowledgment of different models of mental health

difficulties and that a ‘one-size-fits-all’ approach is contrary a person-centred ethos of care

(Department of Health, 2016; Stiles, Barkham, Mellor-Clark, & Connell, 2007) has resulted in

the proliferation of culturally-adapted psychological interventions to meet the needs of

diverse societies and communities (Degnan et al., 2017). While many, if not most, mental

health intervention and/or service models subscribe to being person-centred, statutory

services are more likely to provide individual-focused (versus family-focused) care, with

implicit assumptions about treatment efficacy across ethnic and cultural groups (see, for

example, NICE guidelines for depression treatment (2009).

Cultural-adaption aims to develop, test and implement models of care that are sufficiently

flexible to deliver interventions tailored to the needs of specific groups (Bernal et al., 2009).

Adapted features include but are not limited to: language (translations/amending the

intervention’s vernacular features), beliefs/model of mental health difficulties and

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intervention content, incorporating cultural, religious and/or spiritual practices and

meaningfully involving families in service users’ care (Degnan et al., 2017). Systematic

reviews suggest that culturally-adapted interventions can be successful at helping their

target groups, even our ability to evaluate the efficacy of adapted interventions against

usual care (Degnan et al., 2017; Edge et al., 2017; Kumpfer, Magalhães, & Xie, 2017; Mejia,

Leijten, Lachman, José, & Parra-Cardona, 2017). Furthermore, evaluating the comparability

of adaptation for different ethnic or cultural groups, diagnoses and languages is critical to

understanding the mechanisms behind successful cultural adaptation ( Degnan et al., 2017).

Cultural adaption frameworks have been developed to guide and/or standardise the

adaptation process (Bernal & Sáez-Santiago, 2006; Hwang, 2009; Degnan et al., 2017).

However, it is unclear how successful the proposed types of adaptations are and how readily

they can be applied across different ethnic, cultural and diagnostic groups. Furthermore,

although cultural adaptation is in line with policy-advocated new ways of working (Mental

Health Taskforce, 2016), exponentially increasing the range/number of culturally-adapted

interventions to meet the needs of different groups is impractical. It could be argued that

providing truly person-centred care, incorporating individuals’ social contexts, would nullify

the need for additional culturally-adapted models. Alternatively, a framework to develop a

single culturally-adaptable model might have considerable merit (Edge et al., 2018).

Overview and Conclusion

A fundamental principle of delivering effective, person-centred care involves acknowledging

individuals’ social contexts, values and models of mental health, disorders and difficulties (see

Gilbert this volume). This is crucial for tackling disparities in mental health including:

disproportionate sources of vulnerabilities, variations in forms of presentation and coping, and lack

of access to culturally-appropriate care experienced by marginalised groups in the context of

increasing globalization and multi-cultural societies (Morgan et al., 2017). Aspects of global mental

health interventions that do not address local, global, cultural, social and structural contexts can

result in negative effects. These unintended consequences can range from barriers to help-seeking;

incongruence between the help seeker and the health care provider’s views of the help seeker’s

presentation and/or treatment; prolonged family burden; and experiences of structural, public, or

internalised stigma and discrimination. Further, given the social distance and power imbalance

inherent in therapeutic relationships, it is important to acknowledge that therapy can be harmful

(Emsley, Dunn, & White, 2010). However, acquiring the competence and confidence to work with

people from different backgrounds is not currently routinely embedded either in healthcare

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professionals’ training or their post-qualifying continued professional development (King,

Cederbaum, Kurzban, Norton, Palmer, & Coyne, 2015). Moreover, we would suggest it is unrealistic

to expect any one therapist to be equally competent at working with all cultures. Greater

recognition needs to be given to providing, where possible, options for help seekers, be it based on

gender, ethnicity or therapy approach. Nor should we conclude that therapists from the same ethnic

background are either desired or perform better that other therapists. If we have one appeal in this

multi-variant world it is: ‘don’t assume – ask’!

World Health Organization (WHO) and other proponents of global mental health argue there can be

no mental health without physical social health. They advocate developing, implementing and

evaluating evidence-based practices that can be scaled up though task-shifting and other methods to

improve access to services or interventions and reduce the global treatment gap for mental

disorders (World Health Organization, 2004). However, these approaches have a strong focus on

mental disorders and interventions conceptualised and developed via Western psychiatric

nosologies. We suggest that more socio-culturally appropriate models such as upskilling

communities with mental health competence to prevent and treat mental health difficulties

(Campbell & Burgess, 2012) and interventions that overtly adopt assets-based community-partnered

practices might prove fruitful in strengthening the evidence base (Edge & Grey, 2018).

Currently, the generalisability of psychosocial interventions across ethnic groups remains unclear

due to underrepresentation of ethnic minorities in clinical trials (Waheed, Hughes-Morley,

Woodham, Allen, & Bower, 2015). Indeed we highlight the need for new versions of intervention to

emerge. Moreover, it is not always West to East. The last 20 years have seen extensive interest in an

integration of approaches such as mindfulness, yoga, Chi Qong and use of a range of Asian herbs.

This paper highlights the importance and challenges for delivering, appropriate compassionate and

effective psychotherapy in the twenty-first century. It requires understanding clients’ models of

mental health difficulties, their needs, social contexts and lived experiences. We suggest that to help

address disparities in mental healthcare, practitioners should be equipped with skills to develop

insights into their clients’ social contexts as well as internal worlds. This a now fundamental and

increasing call across a range of therapies that underpin this whole special issue of this journal.

These developments are essential if we are to provide harm-free care and work effectively with a

range of individuals with whom we might have little in common.

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