Culturally adapted cognitive behaviour therapy for Māori with major depression

Internet-based cognitive behavioural therapy in the real world: Naturalistic use and effectiveness of an evidence-based platform in New Zealand

OBJECTIVE

Internet-based cognitive behavioural therapy (iCBT) is an efficacious, scalable intervention that could help meet the significant demand for psychological treatment. Yet, there is limited real-world evidence for its effectiveness. This study investigated the use and effectiveness of a free iCBT programme ('Just a Thought') in New Zealand.

METHODS

We analysed 18 months of user data from the Just a Thought website to understand the characteristics of those who used the Depression and Generalised Anxiety Disorder courses, how many lessons they completed, how mental distress changed across each course and the factors associated with adherence and improvement in mental health.

RESULTS

The results for both courses followed very similar patterns. Course adherence was low overall. There were small differences in adherence by age, gender and ethnicity, and larger differences for those who were 'prescribed' Just a Thought by a healthcare worker. Mixed models showed significant reductions in mental distress, with some tapering of improvement across latter lessons. Those most likely to show clinically meaningful reductions in mental distress had completed more lessons, were older and had a higher baseline level of distress.

CONCLUSION

Alongside previous efficacy research, this real-world data indicate that iCBT is most likely to be effective at the population level and across different subgroups if users complete as much of the course as possible. Strategies to increase course adherence and maximise the public health benefits of iCBT include healthcare workers 'prescribing' iCBT and tailored solutions to meet the needs of young people, Māori and Pasifika.

Therapist Voices on a Youth Mental Health Pilot: Responsiveness to Diversity and Therapy Modality

This article explores therapists' views on a large youth mental health pilot project (for 18-25-year-olds), which included an individual cognitive behavior therapy (CBT)-informed individual therapy component. Therapists' views on cultural responsiveness, therapy (delivery, modality and duration) and working with LGBTQIA+ youth were explored using two surveys, individual interviews and focus groups at various stages of the life of the pilot. Some therapists saw the CBT approach as imposed on them, preferring familiar therapy modalities. Many therapists were positive toward CBT for its client-centered approach and reported using CBT-informed approaches with many of their clients to good effect. Some therapists felt pressured by their workplace to see clients for fewer sessions than they needed. Therapists wanted to see a more culturally diverse workforce, to increase their cultural competence through training and to have more easily available cultural supervision. There was some acknowledgement of the importance of training therapists to work competently with LGBTQIA+ young people. Involving therapists in co-design of services from the outset will likely benefit future service development.

Systematic review of Indigenous involvement and content in mental health interventions and their effectiveness for Indigenous populations

OBJECTIVE

To assess the effects of psychological, psychosocial, educational and alternative interventions on mental health outcomes of Indigenous adult populations in Australia, Canada, New Zealand and the United States and the Indigenous involvement and content in each study.

METHODS

We systematically searched databases, key journals and gray literature, for records until June 2020. Eligible studies were in English or French and examined the impact of interventions on mental health outcomes including anxiety disorders, posttraumatic stress disorder, depression, psychological distress or stress for Indigenous adults (⩾16 years). Data were extracted using a modified Cochrane Data Extraction Form and the Template for Intervention Description and Replication. Quality was evaluated using the Effective Public Health Practice Project quality assessment form.

RESULTS

In total, 21 studies were eligible, comprising 8 randomized controlled trials, 10 single-group pre-post studies and 3 pre-post studies with comparison groups. Twenty studies had Indigenous individuals or organizations involved in some decision-making capacity, though extent of involvement varied widely. In total, 9 studies were rated moderate and 12 weak in the Effective Public Health Practice Project quality assessment. Eight studies measuring depression, three measuring posttraumatic stress disorder, three measuring psychological distress and two measuring stress showed statistically significant improvements following the intervention.

CONCLUSION

A wide range of interventions demonstrated mental health improvements. However, it is difficult to draw generalizable conclusions on intervention effectiveness, given heterogeneity among studies. Studies should employ a thorough assessment of the Indigenous involvement and content of their interventions for reporting and for critical consideration of the implications of their research and whether they address Indigenous determinants of mental health.

He kākano ahau – identity, Indigeneity and wellbeing for young Māori (Indigenous) men in Aotearoa/New Zealand

This article examines how dominant Eurocentric approaches to mental health are unable to address the diverse needs of young Māori men in Aotearoa/New Zealand. Drawing on current health inequities facing Māori and young Māori men in particular, this commentary explores how colonisation has impacted young Māori men in negative ways. Through shaping current health structures in Aotearoa/New Zealand, dominant Eurocentric approaches foreground individualised conceptualisations of Māori ill-health, and then apply predominantly Western therapies to resolve this. These approaches are ill-equipped to address the intergenerational and structural issues which are at the root of mental health disparities for young Māori men. This article adds to a growing body of Indigenous psychology literature that speaks to the inadequacies within (mental) health systems for addressing the ongoing challenges that Māori experience due to colonisation. It further highlights how the intersections among ethnicity/race, class, age and masculinity for Māori men are shaped by colonial discourses. These inadequacies reflect a broader issue of the constraints placed on Māori self-determination by the colonial systems of power in Aotearoa/New Zealand. The article closes by proposing some alternative approaches to supporting Māori wellbeing that centre the needs and aspirations of Māori.

Barriers and Facilitators of Access to Psychological Services for Indigenous Populations: A Scoping Review and Thematic Analysis

Background: The extent to which behavior-analytic interventions are offered to Indigenous populations across CANZUS in accessible and culturally appropriate ways is unknown. We conducted a scoping review with a thematic analysis of the extant literature to find: (1) what are the barriers and facilitators for providing effective and equitable delivery of psychological services (with a behavioral component) to Indigenous populations; and (2) what tools and practices exist for an effective and equitable service delivery. Methods: We systematically reviewed Medline, CINAHL, PubMed, PsycInfo, Web of science, Ovid and INNZ databases between 1990 and 2020. For the scoping review, we adhered to the JBI methodological approach (2015) and the PRISMA strategy for the identification, selection, and appraisal of the reviewed articles. A total of 1265 unique articles met the criteria for the screening by title; 238 by abstract; 57 were included for full text assessment; and 37 were included in the final analysis. Results: Three themes were revealed to account for the barriers and facilitators of culturally friendly practices: (1) connecting practices are about interactions shaping the relationship between service provider and service client; (2) innovative practices test new approaches and innovations that could facilitate access to psychological services and overcome barriers, and (3) reflective practices are about critically examining the processes and actions undertaken toward effective cultural adaptation of services. Conclusions: Our analysis suggests that the level of success in bringing together services and the recipients of treatment (connection), showing flexibility and persistence in finding solutions (innovation) and examining the role of our behaviors in reaching our goals (reflection) is determined by the providers' action in the aforementioned three dimensions of practice.

Treatment outcomes in depression: reducing drop-out rates in cognitive therapy

Although cognitive therapy is a promising treatment for depression, high drop-out rates and, conversely, the specific elements that make the intervention effective continue to puzzle practising clinicians. This article discusses both therapist-related factors (including competence and competencies) and patient-related factors (such as engagement in therapy and external logistical problems with attendance) that are related to drop-out and suggests practical ways to address them and improve outcomes. It examines cognitive and behavioural elements of manualised cognitive therapy and discusses findings relating to cognitive–behavioural therapy (CBT) in particular.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Considerations for Culturally Responsive Cognitive-Behavioural Therapy for Māori With Depression

A strong case can be made for adapting cognitive-behavioural therapy (CBT) for ethnic and cultural minority groups. In North America, literature is readily available for CBT practitioners wishing to adapt their practice when working with ethnic minority groups (e.g., Latino, African-American, and Native American groups). In other countries such as New Zealand, literature of this sort is scarce, and the empirical foundation for CBT adaptation in these parts of the world is weak. This article documents the core tenets of an empirically validated CBT treatment protocol tailored for individual delivery to Māori clients suffering from depression in New Zealand and developed through consultation with an expert advisory group consisting of senior clinicians and Māori cultural experts. The result is a series of considerations for clinicians endeavouring to provide culturally responsive CBT with Māori clients, who are identified and organised into four domains. Two case studies are presented to illustrate the practical application of the proposed techniques. Links are made to international literature related to the adaptation of CBT in pursuit of cultural responsiveness.