Written by Danielle L. Currin, MA and Erica D. Marshall-Lee, PhD, ABPP on behalf of the Atlanta Behavioral Health Advocates
When I was completing a practicum at a college counseling center, my supervisor encouraged me to ask all my clients the following question: “What parts of your identity are most impactful for you?” Not only did this offer an opportunity for these young adults to reflect on their own identities, but it stressed for me the importance of foregrounding identity when considering interventions. This quickly became apparent with a student I worked with whose parents had immigrated from East Asia. Instead of encouraging him to pursue a value-driven major like literature instead of a parent-driven major like computer science, I explored with him the cultural values he was upholding by deferring to his parents’ wishes and in what ways he could simultaneously honor his passions. The “one-size-fits-all” therapeutic approaches I had been taught were, in fact, more like “all-fit-one-size.” Rather than a single approach being accessible to most clients, most approaches seemed accessible primarily to the White majority for whom they were developed.
The field of psychology has a less-than-pristine history when it comes to the inclusion of minoritized populations in the development and dissemination of mental health services within the United States. Many of the practices, from therapeutic intervention to neuropsychological assessment, that we consider evidence-based treatments (EBTs) were developed through a Western lens, primarily by and for White adults. Whether consciously or not, psychologists often employ a “good enough” mentality when providing these treatments to individuals for whom they were not developed. The idea of adapting EBTs for people with various identities is not new (Fuertes et al., 2001; Lau 2006). However, even as these considerations have become more emphasized in training and practice, we see a continued treatment gap (Joiner et al., 2022; Lorenzo-Luaces et al., 2024). Even as our approaches to developing and delivering therapy have evolved, it is still not accessible to everyone.
Digital mental health interventions (DMHIs), from companion apps to virtual therapy sessions, are one such modern development that purports to increase the accessibility of mental health services. Research investigating the impact of DMHIs on various populations (Goodarzi et al., 2023; Jones et al., 2020) and symptom presentations (Firth et al., 2017; Forman-Hoffman et al., 2021) has supported them as an efficacious method for connecting people with psychological services, particularly individuals living in “therapy deserts” or who may have difficulty accessing physical clinic spaces. However, potential for accessibility does not equate to universal benefits in terms of engagement and outcome. Some recent research has found that such characteristics as gender, age, and race significantly influence these benefits (Aschbacher et al., 2023). However, a brief acknowledgement that these identity factors impact engagement and outcome runs the risk of missing the nuances of what may lead certain groups to engage with these services differently than others, particularly when considering culture and race.
Much as researchers and providers have worked to adapt EBTs for minoritized and underrepresented populations, we also have a responsibility to examine DMHIs for efficacy and accessibility for more than the “default” White consumer. Several research groups have already begun to investigate questions of accessibility and relevancy regarding DMHIs, with wide-ranging findings. Over 40% of the time mental health apps are investigated, accessibility for marginalized groups is not considered (Ramos et al., 2021). This includes not just racial and cultural considerations, but adaptations for the visual- and hearing-impaired. Research samples included in the development of DMHIs often consist of primarily White participants, even with the emergence of culturally adapted DMHIs (Ellis et al., 2022). This lack of consideration for diversity in the user database can translate into apps that are too costly, not user friendly, or even culturally insensitive. On top of these concerns, research has shown that several barriers exist that may prevent individuals or groups from utilizing DMHIs. These include user-related (e.g., mental health status, demographics), program-related (e.g., perceived usefulness, social connectedness), and environment-related (e.g., privacy, implementation) factors (Borghouts et al., 2021). Not surprisingly, knowing the audience and what concerns they may have about the resource can influence how likely they are to use it.
Consider the recent development of a phone-based mindfulness app for African Americans. The group’s pilot study, which involved the development and distribution of an app made to address specific concerns raised by African Americans seeking mental health support, found significant decreases in stress levels and increases in emotion regulation capacity (Watson-Singleton et al., 2021). The research that this group dedicated to determining what characteristics might be most attractive to a minoritized population (e.g., voice recordings being done by people of color) made a difference in not only engagement with the app, but also its efficacy.
The bottom line for any mental health provider is that identity and culture are not additional factors to consider in treatment, but essential components of the work we do with our clients. When it comes to in-person interventions, all the fidelity in the world amounts to little if the client does not find it useful or accessible. The same applies to digital interventions. We can use our personal resources to be mindful of what apps may be of most use to our clients, whether through discussing with colleagues or using a curated list of expert-reviewed apps like the One Mind PsyberGuide. Additionally, our clients may tell us directly or indirectly what isn’t working for them, and it’s up to us to hear them. Does that online self-guided skills training module cost more than your client is able to pay? Is your devout Christian client showing hesitation about using a mindfulness app that leans heavily on its roots in Eastern religions? As providers, we have a responsibility to provide the best care to our clients, and that means offering not just the most popular treatment or one that worked for another client, but one that this client is most likely to use and benefit from. Our skills of listening with curiosity and adapting to the needs of our clients remain powerful tools as we navigate an increasingly digital therapeutic world.
