Can online therapy be adapted to be made more inclusive?

29 May 2018

Ethnic diversity in the UK is ever increasing, and research has shown that those from Black, Asian and minority ethnic (BAME) communities are more likely to be diagnosed with mental health problems. The Mental Health Foundation states: ‘Different ethnic groups have different rates and experiences of mental health problems, reflecting their different cultural and socio-economic contexts and access to culturally appropriate treatments.’ Based on this, it’s important to realise that a one size fits all treatment model won’t work and cultural adaptability needs to be taken into consideration.

I have been working for almost 20 years in the development and implementation of online mental health therapies. Like many others in the research community, I am based in a high-income western country. Online therapies, such as SilverCloud Health, have been shown to be effective in these high-income countries. However, little is known of their potential for use in lower income countries or specific cultures.

Working in Colombia

During my career I have been fortunate to have had the opportunity to work at a university in Colombia. As a Research Professor in Psychology, I quickly came to learn that mental health services in Colombia are extremely limited – partly due to the taboo around mental health, but also the cultural reservation around admitting mental health problems and knowing how to find treatment. Services are so limited that 85–95% of individuals with mental health problems in Colombia do not access or cannot access the services they require (Ministerio de Proteccio ́n Social, 2003). Past research has shown that psychotherapy can be effectively adapted for different cultures, however, there hasn’t been much exploration of digital mental health solutions adaptability. Any work on adapting digital interventions have not been systematic in their approach or theoretically driven.

When looking to implement an online therapy tool for use in a different country, considerations need to be made to ensure the tool is adaptable. Some of these considerations are societal or religious such as symbolism, cultural taboos around meaning of mental health and differences in the definition of depression. Other changes are based on language differences, such as idioms and use of metaphors. Even differences in the presentation of depression, for example in Colombia we see a more somatic presentation [headaches, stomach aches] – which is very different to western countries that present cognitively [beliefs about what’s happening, cognitions or thoughts].

Trialling online therapy abroad

In Colombia, the internet is quite easily accessible via phones or for students, via university computers, meaning that credible online treatments are a good option – 58% of the population are internet users.

SilverCloud Health’s Space from Depression programme is an effective evidence-based cognitive behavioural therapy treatment for people experiencing low mood and depression. Built in conjunction with leading clinical and subject matter experts, Space from Depression is an easy to follow programme that includes a range of self-administered tools, activities and education, in a safe and confidential space. The programme supports people by equipping them with a toolbox of techniques to manage their depression.

When SilverCloud Health platforms were initially developed for people in the UK, cultural differences were considered. We initially had discussions around translating SilverCloud for minority groups in the UK, however, we found that those from minority groups seeking treatment tended to be first or second generation, and therefore were looking for treatment in English. As a result, we produced videos, examples and personal stories with a broad ethnic diversity that is representative of the population, and therefore users can be mirrored in their own lives and experiences, which helps to increase engagement and produce positive outcomes.

Following funding from the Irish Research Council, I have been working closely with a Colombian PHD student of mine at Trinity College in seeking to develop a theoretically informed methodology for the systematic adaptation of an internet-delivered intervention for depression and to examine its effectiveness in a Colombian population. This is the first systematic approach to culturally adapting an online intervention and the results will be published later this year, so watch this space.

Derek is the Director of Clinical Research & Innovation at SilverCloud Health. He holds a PhD in psychology and specialises in online delivered interventions for mental health.