In the dying embers of the Covid-19 pandemic, we are left with a much-changed social, cultural, and economic landscape. Masks are considered ‘haute couture’ and hybrid working is here to stay (ONS, 2022). With the increasing reliance society places on virtual spaces, how does this then translate into a therapeutic setting?
This push towards online-based interventions has seen a rise in the popularity of electronic mental health therapies (eMH) (Ellis et al., 2021). Based on the idea that psychological services may be provided online synchronously (i.e., face-timing a therapist), or asynchronously (i.e., chatting via email), it’s easy to see the appeal of such a platform. With some evidence suggesting that online is equally as effective as in-person sessions (Andrews et al., 2018), the question then turns to how well adapted eMH is towards marginalised groups who may benefit the most from such a service.
Having worked in a Covid-19 isolation unit for refugees, the importance of culturally-inclusive practice is undeniable. Promoting trust, connection, and representation is the key when working with diverse populations, as Google Translate can only go so far.
Research by Narayan and colleagues (2022), attempts to bridge this gap by assessing the cultural sensitivity of eMH therapies. In this exploratory study, marginalised service users shared their lived experiences of both synchronous and asynchronous eMH therapies for anxiety and depression.
During a 13-month mixed-methods study, Narayan and colleagues (2022), assessed eMH experiences of marginalised or culturally diverse populations (CDPs) in Vancouver, Canada using two methods of data collection:
- A cross-sectional survey (n=136). The participants were recruited using purposeful sampling. Most identified as Asian (83%), female (65%), and within the 19-34 age range (72%). The survey included questions about the motivations for using asynchronous eMH and the perceived effectiveness of eMH on overall wellbeing. Validated psychometric scales assessed the cultural responsiveness of eMH services (Cultural Responsiveness Questionnaire (CRQ)) and the depressive and anxiety symptoms of participants (Patient Health Questionnaire (PHQ-2) and Generalized Anxiety Disorder (GAD-2) respectively).
- Four semi-structured focus groups (n=14). Most identified as female (64%), South Asian, Chinese or Southeast Asian, and were between the ages of 19-73 (standard deviation 17 years). Participants shared their lived experiences with synchronous and asynchronous eMH services both online and in-person.
Most survey participants were aware of electronic mental health therapies, with 79% reporting using eMH services before. The main findings included:
- The most popular eMH resource was mobile applications, with 43% of participants reporting that they used this form of therapy at least once per week for anxiety, depression, and overall wellbeing. Other popular applications were websites, online videos, and online programmes.
- Approximately 61% reported general satisfaction with eMH, stating accessibility, convenience, and cost-effectiveness as motivators for use.
- Reasons for dissatisfaction were scarcity of tailored information and lack of human connection.
- Most reported that resources were available in their chosen language. However, despite this, about a quarter of those surveyed cited a need for greater representation and promotion of eMH towards CDPs.
Subsequently, three themes were identified from the focus groups as follows:
Limited language diversity
Participants noted the challenges with the use of academic language in eMH resources. Reporting that more diverse and simplified languages could help bring awareness to new immigrants or monolingual elders.
it would be really nice to have it in other languages….something that would reach out to say ‘its ok to try this out’.
This diversity could then help promote increased acceptance of eMH therapy.
Cultural representation and competency
Opinions were mixed regarding cultural representation and competency in eMH therapies. Some service users reported that there was an opportunity to ‘speak with someone of your own ethnic group’, whilst others shared the feeling of ‘if you don’t comply….you essentially don’t have access’. However, there appeared to be a consensus for improvement by including more culturally specific information and cultural biographies of available counsellors.
Most participants reported intense stigma towards mental health in their communities. Many agreed that eMH could help combat this stigma, as those worried about social judgment could access therapy ‘in the privacy of their own home’. Some participants highlighted the need for eMH to provide resources on how to actively address stigma around mental health in marginalised communities.
Overall, this study provides the most recent and up-to-date evidence for the cultural responsiveness of eMH therapies for culturally diverse populations (CDPs) in Canada. Whilst most participants reported using eMH therapies at least once a week, several barriers to access were noted. It seems that despite a wide range of language options, there appears to be a lack of true diversity. Certain groups feel as if they are not represented and that these services may not truly reach minorities such as new immigrants unaware of such support. As these technologies could be the best method of targeting the stigma surrounding mental health, a more nuanced cultural approach beyond language translations is needed.
Strengths and limitations
A key strength of this study is that it bridges the research gap between cultural responsiveness and eMH. Use of a mixed-methods design allowed for detailed and contextualized information via the focus groups, whilst facilitating generalisability with externally valid data from the survey. Although efforts were made to include a representative sample, most participants identified as Asian and female, partly due to the ethnic breakdown of Metro Vancouver (Statistics Canada, 2022). This makes it difficult to generalise findings as a cohort effect is a possibility.
A further constraint is that the study was only available to those who spoke English or could provide their own translator. This screening tool therefore excluded individuals in lower socio-economic brackets who could have provided valuable insight and perspective. In a study that attempts to assess the cultural sensitivity of eMH therapies, having access to the opinions of arguably the most marginalised group would have been beneficial. On the other hand, a benefit of purposeful sampling is that it offers more precise results as information is collected from the best-fit participants. However, those who are less proactive or do not have access to the internet may have been unintentionally excluded.
The use of a cross-sectional study design allowed the authors to retain a significant amount of data from participants which improved the reliability of results. However, in a study targeting CDPs, non-responses are just as valid and could potentially provide insight into how sensitive eMH therapy is towards hard-to-reach groups. Additionally, the lack of any other published surveys regarding eMH reduces the validity of the results collected.
Unfortunately, there was a lack of discrepancy between synchronous and asynchronous eMH experiences. Participants were asked about both, however, there was no clear or concise evidence as to the effect of one form of therapy over another. This would have been a useful grouping tool for further research and comparison of themes across groups.
Implications for practice
The findings have important implications for accessible and culturally responsive eMH therapies going forward. It is imperative that in this new digital age, mental health resources evolve and adapt to online spaces. It is important to recognise that diversity should not solely be measured on translated forms of Westernised therapies. For example, in services supporting refugees, one of their main worries has always been ‘how well accepted is my culture in this community’. Therefore, in order to provide true culturally responsive care, there is a need to adapt resources and train professionals via affirmative action to actively challenge biases and stigma often ingrained in Westernised forms of therapy. Moreover, educational materials on how best to challenge stigma in different cultural settings should be available in eMH therapies.
Participants noted that there was a lack of culturally tailored information when accessing eMH resources. A potential solution may be found by providing information biographies of the available therapists or feedback reports from service users. This serves the dual function of reducing stigma and potentially increasing uptake in eMH therapies for CDPs.
In order to build on the seminal work conducted by Narayan and colleagues (2022), more research must be conducted to further validate the steps taken in this study. Replication of the current study with a larger sample size and not limited to only a Canadian population is crucial to fill the large gap in the literature. Additionally, research into the specific historical and cultural implications of migration patterns and how these impacts the perceived responsiveness of eMH therapies might also be useful if we wish to be able to generalise findings globally.
Statement of interests
King’s MSc in Mental Health Studies
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Narayan, S., Mok, H., Ho, K., & Kealy, D. (2022). “I don’t think they’re as culturally sensitive”: A mixed-method study exploring e-mental health use among culturally diverse populations. Journal of Mental Health, 1–7.
Andrews, G., Basu, A., Cuijpers, P., Craske, M. G., McEvoy, P., English, C. L., & Newby, J. M. (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. Journal of Anxiety Disorders, 55, 70–78.
Ellis, L. A., Meulenbroeks, I., Churruca, K., Pomare, C., Hatem, S., Harrison, R., Zurynski, Y., & Braithwaite, J. (2021). The application of e-mental health in response to covid-19: Scoping review and Bibliometric analysis. JMIR Mental Health, 8(12).
Government of Canada, Statistics Canada. (2022, June 14). Index to the latest information from the census of population. this survey conducted by Statistics Canada provides a statistical portrait of Canada and its people. the census is a reliable source designed to provide information about people and housing units in Canada by their demographic, social and economic characteristics. information from previous censuses is also available. Census of Population. Retrieved December 1, 2022, from
Office for National Statistics (2022, May 22) Is hybrid working here to stay? Retrieved November 27, 2022.
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