Dr. Neil Aggarwal is a professor of clinical psychiatry at Columbia University and a research psychiatrist at the New York State Research Institute. His research expertise is in cultural psychiatry and medical anthropology, specializing in cross-cultural assessment, cultural formulations within mental health, and structural barriers in mental health care. We asked him about cultural risk and resilience factors, minority stress factors, and culturally adapted mental health interventions, particularly for Asian Americans. Here is what we learned from him. 

Start from specific cultural domains.

There is significant heterogeneity both across and within racial-ethnic groups. For example, according to the 2020 US Census, within the United States, there were 24 million people who identify as Asian alone and in combination with another race. The Asian American population has great diversity in demographic traits and, thus, needs. Therefore, there isn’t one solution or way to effectively fit the diverse needs of this group. 

Dr. Aggarwal describes that in cultural psychiatry, they “look at specific domains of culture as it relates to mental health” and then “ask how they are relevant to the people in front of [them].” For example, social support and relationships can be both resilience factors and sources of stress for people. Friends and family can provide positive social support and cause harm or additional stress at other times.

Balance cultural competence skills.

Dr. Aggarwal also discusses the importance of balancing general cross-cultural competence skills with contextual cultural competence skills. Given the internal diversity of racial-ethnic groups, general to-do lists may “unintentionally risk perpetuating stereotypes from people who are otherwise well-intentioned.” 

To avoid making overbroad generalizations or assumptions, it may be helpful to ask people a set of questions about their perceptions of the presenting problem and treatment, such as: “How severe is [the problem]?” “What makes it better?” “What makes it worse?” “What are [your] goals... [and] treatment preferences?”

Think about clinical goals more broadly and contextually.

While looking specifically at culture is important, Dr. Aggarwal also advises that we “de-center from the idea that it's culture that determines goals and think about this more broadly.” Diagnosing people using DSM categories and focusing on symptom remission is just one way of thinking about treatment and clinical goals. It may be useful to characterize clinical goals contextually and consider how they manifest in people’s lives. For example, some people may focus on symptom remission, while others may want improvements in clinical functioning, quality of life, or satisfaction with clinical services. 

One way to do this is by using the Cultural Formulation Interview (CFI; Jarvis et al., 2020), which helps providers incorporate the patient’s perspective and social context. The CFI has specific domains to understand the client’s conceptions of distress, explanations for symptoms, and coping. Training to administer the CFI is available through the Center of Excellence for Cultural Competence.

Understand barriers related to intersectional identities and social determinants, particularly for immigrants.

When considering how culture influences mental health care, it is also important to examine cultural and socioeconomic barriers. Aspects of a person’s identity, such as age, race, and religion, interact with social determinants of health like health care access, neighborhood resources, and migrant status in uniquely intersectional ways. 

Stigma is a key cultural barrier that impacts people’s openness to talking about seeing a provider, how they view the causes of mental health conditions, and their preferred treatments. Dr. Aggarwal states that “in places like where I practice... [and] maybe in other cities in this country... talking about seeing a mental health provider is [a] rarity... people tend not to talk about it, worldwide.” It is also important to remember that there are still within-group differences in perceptions of mental health care and treatment preferences. 

Another significant barrier to mental health care is financial status. It is a privilege to be able to take time off work, access transportation, or co-pay for services. This barrier can be both cultural and socioeconomic. For example, “...if somebody is paying for workplace-based insurance... maybe they don't think to check their benefits [because] they don't necessarily think that mental disorders fall within the realm of biomedical care.”

Consider how migrant status and cultural background impact treatment.

Providers should also consider how minority stressors may influence therapy preferences. For many people, migrant status can have a significant impact on treatment. It may influence how they pay for services, whether they have concerns about being reported for seeking care, or whether they feel comfortable discussing certain issues like intimate partner violence or workplace discrimination. 

Additionally, language fluency may also impact patients’ communication styles. According to the 2023 American Community Survey, about 23% of people speak a language other than English at home, and about 39% speak English less than very well. Since very few psychologists can provide care in a language other than English, patients may not be able to see a provider who shares their linguistic background or uses the same communication style as they do. This is problematic because having a provider who speaks the same language is associated with positive effects on service use, treatment retention, and patient perceptions of provider credibility (Chu et al., 2016). 

Furthermore, people may have different preferences for the format of treatment based on their identities and perceived issues. Some patients may want “... more directive forms of care when they go in for talk therapy versus... exploratory psychodynamic therapy or psychoanalytic therapy.” Others may be more comfortable speaking in a group or family therapy setting versus individual therapy, and Dr. Aggarwal reminds us that there are risks and benefits to weigh with either approach.

Pay attention to both sides of the treatment interaction and the environment.

Additionally, while examining how patients are impacted by culture is important, it is equally important to evaluate the provider side of the cross-cultural interaction. Dr. Aggarwal suggests that to avoid pathologizing patients, we should ask ourselves, “What are the dynamics or the emotional responses [we are] feeling? How do we chart [without] assuming that certain findings are just due to the patient...is it the way that somebody asks questions? Is it the institution that's influential and eliciting certain responses...?” He also recommends using a model of intersubjectivity (Foster, 1999) to examine how our biases, prejudices, and the dynamics of transference/countertransference may influence patients’ responses. 

One way to do this is by considering the treatment setting. For example, there are different considerations for treating patients in inpatient versus outpatient. Dr. Aggarwal reminds us that “...in outpatient therapy, when people might prematurely discontinue services or when there is greater freedom for the [provider] to act with professional autonomy, then issues of transference and countertransference become really important to think about because then it goes into engagement... like appointment retention and treatment adherence.” Patients and providers exist in context. Therefore, in addition to individual patient and provider factors, it is important to consider how these factors interact together in a system as interpersonal patient-provider factors (Chorpita & Daleiden, 2014). 

Key takeaways.

Dr. Aggarwal discusses five specific steps (listed below) that providers can take to culturally adapt mental health care. By considering culture and context, we can change how we think and practice mental health care to improve outcomes for racial-ethnic minoritized patients. 

1. Start from specific cultural domains. 

2. Balance cultural competence skills. 

3. Think about clinical goals more broadly and contextually. 

4. Understand barriers related to intersectional identities and social determinants. 

5. Pay attention to both sides of the treatment interaction and the environment.

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References:

• Chorpita, B. F., & Daleiden, E. L. (2014). Structuring the Collaboration of Science and Service in Pursuit of a Shared Vision. Journal of Clinical Child & Adolescent Psychology, 43(2), 323–338. https://doi.org/10.1080/15374416.2013.828297

• Chu, J., Leino, A., Pflum, S., & Sue, S. (2016). Psychotherapy With Racial/Ethnic Minority Groups: Theory and Practice. In A. J. Consoli, L. E. Beutler, & B. Bongar (Eds.), Comprehensive Textbook of Psychotherapy: Theory and Practice (2nd ed., pp. 346–362). Oxford University Press.

• Foster, R. P. (1999). An intersubjective approach to cross-cultural clinical work. Smith College Studies in Social Work, 69(2), 269.

• Jarvis, G. E., Kirmayer, L. J., Gómez-Carrillo, A., Aggarwal, N. K., & Lewis-Fernández, R. (2020). Update on the Cultural Formulation Interview. Focus, 18(1), 40–46. https://doi.org/10.1176/appi.focus.20190037

• US Census Bureau. (2022, May 25). 20.6 Million People in the U.S. Identify as Asian, Native Hawaiian or Pacific Islander. Census.Gov. https://www.census.gov/library/stories/2022/05/aanhpi-population-diverse-geographically-dispersed.html

• US Census Bureau. (2023). American Community Survey 1-Year Estimates Subject Tables [Dataset]. https://data.census.gov/table?t=Language+Spoken+at+Home

Additional resources:

• Interview summary (PDF)