Culturally Responsive Psychoeducation Guide
Goals:
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Co-create an understanding of the presenting problem and a treatment plan that takes into consideration how anxiety and OCD function within the client’s cultural context.
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Normalize experiences and instill hope that the tailored treatment plan can help them meet their goals.
Psychoeducation begins during the initial assessment and continues throughout treatment. Formal psychoeducation is typically delivered after an initial case conceptualization and serves as the first step in treatment. Ex-CBT always begins with psychoeducation about how anxiety and OCD conditions develop and are maintained. It also includes explicit information about the rationale for exposure practice to build motivation within the youth and family to make changes and empower them to do things that feel hard or overwhelming. An important goal of psychoeducation is to develop a shared narrative of a client’s mental health difficulty and how the treatment plan will address their concerns.
We provide specific guidance on how to incorporate what we learn from the cultural assessment into psychoeducation so that clients feel heard, respected, and that treatment is responsive to their unique cultural context.
The principles below can be applied to any youth struggling with anxiety or OCD and are particularly relevant for youth with marginalized and minoritized identities.
Guiding Principle #1
Discuss the role of avoidance both in protecting against harm and maintaining anxiety. Emphasize the importance of learning to break maladaptive cycles of avoidance through gradual, supported exposure practice. For OCD cases, explicitly discuss how compulsions relate to the cycle of avoidance. Include in this discussion the ways in which avoidance may be serving a protective role. The idea of exposure practice is naturally scary, and it is critical that youth and families understand the rationale for facing scary things on purpose.
Intended Impact: Demonstrate that you understand that some avoidance may be adaptive and that you will never ask them to engage in exposure practice that could put a child in intentional harm’s way. Communicate the rationale for exposure.
Guiding Principle #2
Culture influences clients’ comfort in discussing or showing emotion. Some cultures think that conversations about difficult emotions are too adult for children. Others place an important emphasis on appearing calm or strong. Understanding each family’s culture around discussing emotions (in addition to discussing how anxiety is a normal and natural emotion that functions to keep us safe from harm and motivate us to stay healthy and be successful) can help you meet families where they are and identify areas where there may be flexibility to make change.
Intended Impact: Develop a common understanding and language around anxiety and OCD.
Guiding Principle #3
Minoritized clients can experience chronic invalidation of their minority stress experiences and are more likely to experience mistrust in their providers than youth of majority background. When Ex-CBT approaches are applied too rigidly, they run the risk of invalidating client experiences by over-focusing on thoughts as irrational and physiological, emotional, or behavioral responses as exclusively maladaptive. Validating the client’s experiences as legitimate allows the family to feel heard.
Intended Impact: Validate the client’s experiences and their physiological, emotional, and behavioral responses to demonstrate you understand their difficulties and are prepared to help.
Guiding Principle #4
Standard psychoeducation regarding how anxiety functions as our body’s alarm system (“fight, flight, freeze”), and how anxiety and OCD arise when that alarm system becomes oversensitive, should explicitly acknowledge how the body’s alarm system responds to chronic identity-related and environmental stressors and incorporate the client/families understanding of anxiety. Some youth, especially those who have experienced chronic stressors, may have developed anxiety alarm systems that can look maladaptive or irrational to an outsider but best be understood as functioning in a protective capacity when considering the youth’s context.
Intended Impact: Understand the effects of chronic stressors to collaboratively determine which alarms are helpful and which are contributing the unnecessary distress. In addition, tailoring the explanation of the maintenance of anxiety to the family’s beliefs can ensure shared understanding of the cause and maintenance of anxiety.
Guiding Principle #5
Explain the potential impact of Ex-CBT to improve symptoms, describing how it is known to be helpful, has been tested in multiple studies, and can work as well as medication to address concerns. Discuss the potential of a combination approach of Ex-CBT and medication to treatment depending on youth response and family comfort. Explain strategies you may use to support youth motivation (e.g., reducing family accommodation, rewards). Throughout this discussion, elicit the client/caregiver perceptions of Ex-CBT and associated strategies to determine how their values align and increase engagement in treatment.
Intended Impact: Clients and families come to therapy with different perspectives of mental health. Some will struggle with the idea of anxiety/OCD or therapy itself. Seeking therapy may also run counter to some cultural norms. Improve engagement and ensure that the treatment plan aligns with the client’s goals, values, and understandings of mental health. Eliciting feedback from the family throughout psychoeducation can help ensure shared understanding of treatment and goals.
Guiding Principle #6
How you deliver psychoeducation is just as important as the content that you deliver for the family to take in the information presented.
Intended Impact: Rarely will individuals be willing to try things that are hard and scary if they do not understand the rationale for doing so. People often come to therapy in an emotional state, which can greatly impact one’s ability to receive information successfully. A collaborative style (in contrast to a didactic, lecturing style) that frequently assesses family understanding and agreement with concepts presented can help you understand how much time to spend in the psychoeducation phase (and when and how to revisit it throughout treatment) and how to tailor the content to move families toward a willingness to try Ex-CBT.