Clinician-Reported Person-Centered Culturally Responsive Practices for Youth with OCD and Anxiety
Abstract
Highlights
- Clinicians working in community mental health clinics described the need to understand their clients’ culture and context and noted ways in which they addressed these factors.
- Clinicians described incorporating culture and context through adapting existing treatment techniques, augmenting treatment with strategies not traditionally included in Ex-CBT, and utilizing process-based approaches.
- Learning from practicing clinicians’ approaches and challenges can help to inform clinical recommendations for more person-centered culturally responsive anxiety and OCD treatment for minoritized youth.
Abstract
1. Introduction
2. Materials and Methods
2.1. Participants
2.2. Procedures
2.3. Data Analysis and Theory
2.4. Positionality
3. Results
3.1. Therapeutic Phase: Culturally Responsive Assessment, Case Conceptualization, and Treatment Planning
3.1.1. Theme 1: Developing a Culturally Informed Conceptualization of the Client and Their Anxious Distress
- 1a. Proactively and Continuously Assessing Cultural Context
“I don’t think in [the clinic] … we did a lot of, like, specific questioning about cultural values. It was more as it came up in the form of barriers … for example, there’s a case of a family that was Muslim and so there were specific views with different members of the family about mental health treatment … specific diagnoses, and medication. … And so it was a little bit, like … reactive, but maybe could have been more proactive.”(Specialty Anxiety Clinic, Clinician 3)
“I don’t really shy away from those topics … if I have somebody that’s sitting in front of me, that’s either a different race, or a different gender or different religion … there’s obviously a dynamic that goes into that.”(General Community Mental Health Clinic, Clinician 14)
“Like, if racial protests are going on, I like to ask how clients are handling it, what their thoughts are on it … if they had ever experienced racial discrimination … I don’t think I go out of my way to talk about it if they haven’t mentioned anything, but if they ever allude to the fact that they’ve experienced discrimination, I do make time for it.”(Specialty Anxiety Clinic, Clinician 5)
- 1b. Understanding Family Cultural Norms and Expectations and their Intersection with Anxiety and OCD
“When you’re working with children …the child’s cultural identity is often very different than the family’s, than the parents,’ or even siblings’. So just holding space for different members of the family system to have very different identities and be really open to exploring that.”(Specialty Anxiety Clinic, Clinician 2)
”If we’re talking about a kid who has OCD religious obsessions … I would really want to know… what do you believe? … I would … involve religious leaders in trying to determine what are … some exposures we can do that might violate what would typically be done? And … trying to recruit people who can provide me with additional information… and identify how that cultural experience intersects with the anxiety and OCD experience.”(Specialty Anxiety Clinic, Clinician 4)
“And understanding the family system, father was [really involved] in the church, and was this an intrusive thought that she was a lesbian, or was it [a] feeling of distress because she might be a lesbian? And how did that intersect with her religion?”(Specialty Anxiety Clinic, Clinician 9)
3.1.2. Theme 2: Taking a Holistic, Systems-Informed Approach to Treatment Planning
- 2a. Determining the Appropriateness of Ex-CBT Techniques within Clients’ Environmental Context
“I get why you have to do this in this specific environment, but let’s … see if it works in these other environments, too. Do these certain things work for you when you’re at school? … And then we get to work on the anxiety in the school setting while they still could keep up their protective factors when they go into these places where they need to have their guard up.”(General Community Mental Health Clinic, Clinician 14)
“Trying to tease apart the realistic nature of the fear versus, like, is this something we should target with exposures, is this something we target with problem solving? … I had a patient who was worried about her parents being deported … and I was, like, that’s a realistic fear, based on what was happening at that time. And so, we had conversations about it that… didn’t use a typical CBT approach … I definitely made adjustments to treatment to help her just cope with the fact that those thoughts are just really big and scary.”(Specialty Anxiety Clinic, Clinician 1)
“She always felt like, on the train, that if somebody moved their bag, that they would have a weapon in there … that she would be a victim of violent crime at any time … And I didn’t want to push her and discount some of the real problems that women face in male violence, right? So, we… talked about why it might still be important [to take the train], what we’re going to keep an eye on … texting her parents if she feels uncomfortable, taking a phone call, carrying mace … things that were safety planning, rather than safety behaviors.”(Specialty Anxiety Clinic, Clinician 5)
- 2b. Addressing Environmental Stressors and Structural Barriers
“A lot of my clients have difficulties with transportation, neighborhood safety … they’re dealing with very real stressors. They’re hungry, they’re trying to figure out where they’re going to live … they can’t focus on more abstract concepts. They’re focused on just surviving. Sessions usually get brought back to those basic needs … allowing that flow in sessions. Because if those things aren’t satisfied or are causing immense stress, then the work we do … isn’t going to be as effective.”(General Community Mental Health Clinic, Clinician 14)
“…seeing my role as not just individual therapy with a child but really considering the big picture and what this family needs … that either I can provide, or I can connect them with someone to provide. So, from a sort of hierarchy and needs perspective, if the family is worried about the parent losing their job … understandably, treatment’s going to fall lower on the priority list.”(Specialty Anxiety Clinic, Clinician 2)
“First, I’m trying to see … how I might be helpful with improving [a client’s] immigrant status … how to help them feel more safe. Many of them do not have insurance … legal income … they do not feel themselves part of this country… and it increases the anxiety, the depression, the other mental health problems.”(General Community Mental Health Clinic, Clinician 11)
3.2. Therapeutic Phase: Culturally Responsive Treatment Delivery and Process
3.2.1. Theme 3: Aligning Ex-CBT Techniques with Client Values and Cultural Traditions
“So, there’s the actual content that I need to deliver … but potentially the way that I communicate it with my style … or who is actually delivering the message is going to be important … I might consider bringing in a religious leader or somebody who can explain it in a way that’s … aligned with their cultural principles.”(Specialty Anxiety Clinic, Clinician 7)
“There are families I work with where it’s really comforting for them to hear that the research suggests this is super effective. And for other families, there’s a lot of understandable suspicion about research. And what they want to hear really is like …I’ve seen this be helpful for kids like yours. So just even the way I communicate messages about effectiveness … often needs to be adapted to what the family is comfortable with and what they value.”(Specialty Anxiety Clinic, Clinician 2)
“I did not adequately assess and consider their parenting beliefs based on their generation, their race, dad’s military background, the neighborhood where they lived … I don’t think that I took enough time to really pause and ask them, like, what are your parenting beliefs? How could this fit with what I’m suggesting?”(Specialty Anxiety Clinic, Clinician 4)
“It’s more about just making sure that the exposures themselves fit in terms of the child’s needs, but also the family’s values, preferences, attitudes, capabilities,logistics—all those pieces.”(Specialty Anxiety Clinic, Clinician 2)
“Our idea of what thoughts are right and wrong comes from our cultural lens … I just need to be really careful that [my framing] actually is aligned with the reality that they experience.”(Specialty Anxiety Clinic, Clinician 4)
“I really have to be careful … I have to make sure that some of the assumptions I’m using when I do flexible thinking, are taking more of a soft, universal approach. Not all cultures believe that you’re allowed to take a step back from school just to work on your mental health … I think that is the most adjustments I have to make.”(Specialty Anxiety Clinic, Clinician 5)
“[It’s] not just about, hey, I have CBT, I had the [exposure and response prevention], and I’m sorry that your religious or personal beliefs don’t align with that. It’s just what we’re doing. [Instead, asking] how can we align, and how can I understand to help you be the best you based upon your needs and really understanding your culture?”(Specialty Anxiety Clinic, Clinician 9)
3.2.2. Theme 4: Incorporating Social Identity into Exposure Planning
“[The client] told me that he had come out as gay and his family … and his community, all kind of rejected it … A lot of the things he would want to do to… be his authentic self were not safe social anxiety exposures for him … There were unrealistic fears related to social anxiety, but then there were also realistic fears related to discrimination, and how do we make sure that our exposures are only targeting the unrealistic fears but not fears that are valid and keeping him safe?”(Specialty Anxiety Clinic, Clinician 2)
“We adjusted to do other public exposures that didn’t… [make] her feel additionally uncomfortable. And I also rethought that … maybe this place is actually higher on her hierarchy and it’s unfair to put her in such a difficult place … So, I did not continue to make her go to a place that she felt racially and socioeconomically uncomfortable, but I didn’t stop doing exposures. We would instead go to … more diverse places, like we would go to the hospital across the street … because it seemed a little more balanced from SES.”(Specialty Anxiety Clinic, Clinician 5)
3.2.3. Theme 5: Engaging in Collaborative Decision-Making and Flexibility
“I would … ask them, like, what do you actually want to work on? So, at least it gives them the autonomy to … decide … And then, usually … I’ll bring up the techniques I used to work with clients in the past. But I also will tell them, sometimes it works with people, sometimes it doesn’t … because everyone’s different … So, I would ask them, how do you feel if you try this? … So, that’s how we end up doing the treatment plan.”(General Community Mental Health Clinic, Clinician 10)
“We’re not [doing] exposures today. I know you have panic attacks. We’ll get back to that … how can I support you? What resources and steps do you need? … I just was like full-on, what do you need from me?”(Specialty Anxiety Clinic, Clinician 1)
3.2.4. Theme 6: Building Trust
- 6a. Building Trust Through Self-Disclosure
“Just naming the differences and naming that you might not understand their experiences because you haven’t gone through it specifically, but you’re here to try and understand … And I found that just by doing that, it builds a lot of trust and just understanding.”(General Community Mental Health Clinic, Clinician 14)
“When clients brought up issues of racial discrimination, I feel like it’s something that needs to be talked about. And I think that … oftentimes a lot of people of color or just people who are oppressed in general don’t really feel like they have the space to speak to about it. And I think that’s one of the ways in which … being a Black woman is helpful, because if that is something people are struggling with, they feel comfortable talking about it.”(General Community Mental Health Clinic, Clinician 15)
“I am gay too, so I have a decent understanding of what the community is about and the basic terms … And it immediately clicked with him … it seemed like he felt thankful that he didn’t have to educate me … I felt a shift in the rapport immediately.”(General Community Mental Health Clinic, Clinician 14)
“I’m always navigating … how much [self-disclosure] do I bring into the space and when and how? And honestly, it’s a place where I would love to get more training. I think it’s still a growth area for me.”(Specialty Clinic, Clinician 2)
“I think the thing that really stands out as … missing from my training was learning—which I’ve just sort of done trial and error—how to self-disclose, and how to talk about my own identity and ask about clients’ identities. Because I actually think that once that’s out on the table … the adapting treatment part comes more easily and naturally.”(Specialty Anxiety Clinic, Clinician 4)
- 6b. Building Trust Through Recognition and Validation of Negative Experiences
“There’s a lot of associations that are unique to our situation [such as Child Protective Services] … I like to be very explicit about, like, what experiences have you had with these other agencies, like, what does this feel like … to have someone come into your house? … Being able to just identify what maybe negative experiences have happened in the past that could be associated with our work in the present.”(Specialty Anxiety Clinic, Clinician 6)
“It’s tough because I think that CBT therapists … want to be really active. And there’s not a solution for [systemic oppression], right? … Sometimes the best we can do is validate and not try to solve it, and certainly not trying to challenge a cognition that’s an accurate one. And … cultivate space, that this is an okay thing to talk about, and it’s not an acceptable thing to be happening and your experience is real. And that’s it … You can’t say, you need to think about this differently, you need to do something differently … And I think as a CBT therapist, that feels super uncomfortable for me, and I have to just sit with that discomfort.”(Specialty Anxiety Clinic, Clinician 2)
- 6c. Building Trust Takes Time
“[Slowing] the pacing of treatment, and potentially spending a lot more time on psychoeducation and rapport-building … is kind of what I wish I had done with a patient, that it didn’t necessarily go super well … We probably tried to move too quickly for what this patient was ready for … both from an individual perspective, but also their cultural beliefs about anxiety and about therapy and our different identities. I think we needed more time to build up rapport and trust before jumping in as much to active intervention.”(Specialty Anxiety Clinic, Clinician 3)
“One of the more challenging parts of the population that … I … currently work with, being in the child welfare system … our kids have had traumatic experiences and absence of… family members … Some kids have lived on the streets for the entirety of their lives and have no family members at their disposal. So, establishing trust is an ongoing thing and it’s a constant challenge … And I’m aware that, due to the nature of the trauma that our kids have experienced in their lives, sometimes a trusting relationship … may take a prolonged period of time, or sometimes it may happen instantly … or never.”(General Community Mental Health Clinic, Clinician 12)
“There’s clients where rapport-building comes with just spending more time getting to know them. And then there’s other clients that are in real distress, and they’re not going to trust you until you show you can help them … I just always had to keep in the back of my head: does this client need more time with me … or do we need to just move forward, and the trust will come?”(Specialty Anxiety Clinic, Clinician 2)
3.2.5. Theme 7: Engaging in Self-Reflection as a Tool to Improve Cultural Responsiveness
“I found that as a White person … or as a male… and all those privileged identities that I hold, that the first instinct is to shy away from those discussions … but I found that that’s not helpful to anybody, including myself. So really throwing myself into those discussions allows the conversation to start. So … reflecting on my own identities and how they might show up in session … has been really helpful at either developing rapport or having people feel understood.”(General Community Mental Health Clinic, Clinician 14)
“I think it is a core aspect of providing ethical, effective clinical care to have those conversations, to be willing to mess up sometimes in the interest of serving the clients and honoring, respecting their backgrounds and tailoring treatment to meet their unique needs.”(Specialty Anxiety Clinic, Clinician 4)
“I used to have a lot of trouble asking about those things without pinning certain values or identities on a client … So, I will pull [the cultural assessment] up … to remind myself of phrasings and wording that I can use that doesn’t assume anything and allows the client to kind of go any direction they want.”(Specialty Anxiety Clinic, Clinician 5)
“Trying to anticipate potential conflicts or cultural issues in supervision would be helpful in case conceptualization, particularly, but also using that to then guide, okay, now you’re planning for this phase of treatment. So, let’s think about what might come up for this family in this context.”(Specialty Anxiety Clinic, Clinician 3)
4. Discussion
4.1. Therapeutic Process Factors to Facilitate Person-Centered Culturally Responsive Care
4.2. Thoughtful Application of Ex-CBT Principles Through Adaptation and Augmentation
4.3. Limitations and Future Directions
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
EBT | Evidence-based Treatment |
Ex-CBT | Exposure-based cognitive behavioral therapy |
OCD | Obsessive-compulsive disorder |
Appendix A
Appendix A.1. Qualitative Interview Guide
Appendix A.2. Treatment Approach
- Let’s start by imagining a child or teenager is (coming to you) seeking treatment for OCD or an anxiety disorder. What would your treatment approach look like?
- a
- If they mention deciding between modalities: Could you walk me through how you decide which treatment modality is best?
- b
- Probe: Could you give me examples of specific treatment techniques you typically might use?
- 2.
- What do you see as the biggest barriers to providing OCD and/or anxiety disorder treatment to youth at your clinic?
- a
- Probe: Barriers to treatment engagement (e.g., attendance, caregiver participation)
- b
- Probe: Barriers to treatment success (e.g., what do you see as getting in the way of youth with OCD/anxiety disorders responding to treatment?
- 3.
- How do you typically address these barriers to engagement or treatment success for youth with anxiety disorders or OCD in your clinic?
Appendix A.3. Cultural Responsiveness
- 4.
- We are going to switch gears a bit to discuss cultural responsiveness. People define this term in many different ways. When you hear the term “culturally responsive therapy,” what does this mean to you?
- 5.
- In what ways, if any, do you assess for cultural or contextual factors (e.g., racial/ethnic identity, gender identity, socioeconomic status, beliefs about mental health and help seeking)?
- 6.
- Thinking specifically about working with youth with OCD or anxiety disorders, in what ways, if any, do you incorporate cultural or contextual factors into case conceptualization or treatment planning?
- 7.
- Have you ever had a situation in which a client expressed that therapy conflicts with their cultural identity or values? If so, please explain.
- 8.
- Sometimes our culture and background, such as the communities we belong to, the languages we speak, where we are from, our race or ethnic background, our gender or sexual orientation, our faith or religion, the neighborhood we grew up in, or how much money we have affect the way that we interact with people. Therapists and clients have aspects of their cultures and backgrounds that are similar and different. To what extent do you reflect on your own intersectional identity and how it influences your relationship with your patient and or the care you deliver?
- a
- Probe: How have similarities or differences in identity created challenges for you and your clients? Feel free to share any deidentified examples you have experienced that come to mind.
- b
- Probe: How have similarities or differences in identity benefited you and your clients? Feel free to share any deidentified examples you have experienced that come to mind.
- 9.
- In what ways have you focused on building relationship and trust with clients with different cultural backgrounds than your own. *can skip if needed*
- 10.
- How comfortable do you feel having conversations about a clients’ cultural background or identity, including experiences with racism and discrimination- and what has informed this comfort?
- a
- Probe *can skip if needed*: Has a client ever disclosed feeling misunderstood within the therapy context?
Appendix A.4. Treatment Adaptations
- 11.
- Have you ever heard of Exposure-Based CBT? *If no go to #13*
- 12.
- Do you utilize exposure-based CBT with patients with anxiety disorders or OCD?
- a
- Probe: How do you use these strategies? Could you talk me through what it might look like for you to use exposure-based CBT with a client with OCD or an anxiety disorder?
- 13.
- If no, they have not heard of Exposure-Based CBT or are not sure, “Exposure-based CBT consists of intentionally helping youth face things they are afraid of and support them to reduce their use of avoidance or compulsive behaviors to ultimately help them learn to manage their distress more effectively. Exposure strategies can include having the client make a list of uncomfortable situations and rank those situations from easy to hard (i.e., build a hierarchy), helping the client gradually face his/her uncomfortable feelings (e.g., anxiety) in a supported way, and reduce the use of behaviors or compulsions that feel better in the short term but maintain anxiety in the long term.”
- a
- If they haven’t used it: What do you think about how useful or not this strategy would be for your patients with anxiety or OCD?
- b
- Probe: What, if anything would be missing?
- 14.
- If yes, they have heard of Exposure-Based CBT, but no they have not used it:Can you tell me little more about why you haven’t used Exposure-Based CBT and what treatment strategies you used instead?
- 15.
- If they have NOT used exposure-based CBT:You told me you use (List strategies they have reported using to treat youth with anxiety/OCD). How, if at all do you personalize these treatment strategies or processes based on your clients’ culture or background?
- a
- Probe: Treatment component they mentioned #1, 2, etc.
- 16.
- Okay, now I want you to think about whether and how you individualize/personalize treatment strategies to better fit your clients’ needs when delivering OCD or anxiety treatment. Standard general exposure-based CBT for anxiety disorders or OCD typically includes providing psychoeducation, hierarchy building, exposure practices, cognitive restructuring and relapse prevention. Please take a moment and think of some specific cases you treated in your clinic to help guide your responses. Of note, please do not share any identifying information with me about those clients. In what ways have you individualized/ personalized treatment strategies or used alternative treatment strategies to improve cultural and contextual fit for your clients (e.g., client/clinician cultural identity, neighborhood context, client values, religious beliefs, gender identity)? Specifically, how have you adapted / individualized:
- a
- Psychoeducation
- b
- Exposure
- c
- Cognitive restructuring
- d
- Other components of treatment
- e
- Probe: Did you find yourself adding any treatment strategies or material not typically in standard Exposure-Based CBT to address culture or context (e.g., strategies to address race, acculturation, discrimination)?
- f
- Probe: Did you find yourself removing elements of standard Exposure-Based CBT?
- 17.
- What components of Exposure-Based CBT do you find you adapt most often to fit your client’s cultural context, and why?
- a
- Are there any other ways you think of adapting treatment?
- 18.
- How do you make decisions about whether and how to individualize/ personalize treatment for your clients? *Summarize previous reasons for individualizing and ask for any additions*
- a
- Probe: Are there any specific symptoms youth may present with that might prompt you to consider incorporating cultural/contextual values more or less? If so, what?
- 19.
- There are many cultural/contextual factors that affect treatment, like: beliefs about mental health and help-seeking; mistrust of providers; social identity and background; immigrant stressors; religion; racism and discrimination, so on. I’m going to send you a list of some of these examples in the chat. [Send this in the chat]: “Family and client beliefs about mental health and help seeking; Client’s mistrust of providers / health care system; Social identity and background (race, ethnicity, gender, SES, age, sexuality, language); Immigrant status/Acculturation stressors; Religion; Racism and discrimination; Social determinants of health (transportation, neighborhood safety, food/housing security, trauma exposure); Parents’ own mental health needs; Cultural values and beliefs.” Are there cultural or contextual factors that are missing from this list?
- 20.
- What are some of the most common factors that come up among your clients? What specific strategies do you use to address these factors or incorporate them into treatment? Please feel free to use de-identified case examples. (Factor #1 they mentioned, #2, etc.)
- a
- Probe if they’re having a hard time: For example, some clinicians might bring the parents or family into a session to create a treatment plan together that aligns with their values. Or when explaining the diagnosis or treatment, framing it in a way that fits with the client’s values. Another example might be consulting with religious leaders or traditional healers.
- 21.
- Have situations arisen where you’ve needed more support to address clients’ cultural or contextual factors in treatment for OCD or Anxiety disorders? If so, please explain. *can skip if needed*
- 22.
- What kind of specific training, supports, or additional strategies, if any, do you think are needed to help clinicians deliver culturally responsive treatment to youth with OCD and anxiety disorders?
- a
- Probe for specifics: What would this look like?
- 23.
- People have different definition of antiracism, based on your own definition, what, if any, antiracism efforts are/were in place within your agency, for example policies and procedures, trainings, focus in supervision? *can skip if needed*
- 24.
- We talked about a lot of things. If you had one key message that you would like me to remember from this conversation, what would that be?
- 25.
- What else would you like to share or any questions for me?
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n = 16 | ||
Age | M | SD |
32.2 | 5.9 | |
Gender | n | % |
Female | 11 | 68.9 |
Male | 5 | 31.3 |
Race/Ethnicity | ||
Black or African American | 1 | 6.3 |
Asian | 4 | 25.0 |
White | 11 | 68.2 |
Themes | Subthemes | Clinical Implications |
---|---|---|
Therapeutic Phase: Culturally responsive assessment, case conceptualization, and treatment planning | ||
Developing a culturally informed conceptualization of the client and their anxious distress | Proactively and continuously assessing cultural context |
|
Understanding family cultural norms and expectations and their intersection with anxiety and OCD |
| |
Taking a holistic, systems-informed approach to treatment planning | Determining the appropriateness of Ex-CBT techniques within clients’ environmental context |
|
Addressing environmental stressors and structural barriers |
| |
Therapeutic Phase: Culturally responsive treatment delivery and process | ||
Aligning Ex-CBT techniques with client values and cultural traditions |
| |
Incorporating social identity into exposure planning |
| |
Engaging in collaborative decision-making and flexibility |
| |
Building trust | Building trust through self-disclosure |
|
Building trust through recognition and validation of negative experiences |
| |
Building trust takes time |
| |
Engaging in self-reflection as a tool to improve cultural responsiveness |
|
Themes | Subthemes | Quotes |
---|---|---|
Therapeutic Phase: Culturally responsive assessment, case conceptualization, and treatment planning | ||
Theme 1: Developing a culturally informed conceptualization of the client and their anxious distress | Proactively and continuously assessing cultural context | “That opens up the conversation about … what was it like for you growing up, what were your family’s values, how is that different from what’s happening now? So … making sure that they know we’re really interested and really care about their perspective and their culture and their experience.” (Specialty Clinic, Clinician 6) “A big part of [cultural assessment] is during the first initial meeting of really trying to get to know them. Or they just really giving them the opportunity to disclose [culture or traditions] if they feel comfortable. And then also … if they don’t feel comfortable disclosing with right away, leave a way to open for them to come back …” (Generalist Clinic, Clinician 8) “So, it really starts with the intake, because … we get a lot of identity, like you said, race, religion, sexual orientation, gender identity, all those things are kind of rolled into our … community mental health’s practice … and then in sessions … when I do information gathering, or just getting to know the person that it comes up.” (Generalist Clinic, Clinician 14) “I think my own progression has been from asking about it at the front end, and sort of thinking that the information I got at the front end was what I needed, to recognizing that this is actually really an ongoing process and continually assessing … [and] coming in with genuine curiosity and humility related to cultural factors.” (Specialty Clinic, Clinician 4) |
Understanding family cultural norms and expectations and their intersection with anxiety and OCD | “Conditions of worth [are] very important … growing up, what were expectations from family, society … the neighborhood you grew up in, the community… or your peers.” (Generalist Clinic, Clinician 10) “I had to really think about what my culture would say about differentiation from your family and what is appropriate … for her age.” (Specialty Clinic, Clinician 5) “If there’s religion-related OCD, compulsions, or fears or obsessions … I needed to understand enough to be able to say … is this an obsession and a compulsion that we need to address? … I talked to mom about it. I talked to [client] about it. We talked about the difference between her still being able to believe in God versus still being able to function in her household.” (Specialty Clinic, Clinician 1) | |
Theme 2: Taking a holistic, systems-informed approach to treatment planning | Determining the appropriateness of Ex-CBT techniques within clients’ environmental context | “I think an obvious example of this is a child who is fearful of police. And if they are Black, that fear is very different than if they are White. … If we just make assumptions of, oh, if every time you hear sirens, you have a panic attack, that must all be out of proportion, I think we’re doing a disservice to a lot of kids.” (Specialty Anxiety Clinic, Clinician 4) “She always felt like, on the train, that if somebody moved their bag, that they would have a weapon in there … that she would be a victim of violent crime at any time … and I didn’t want to push her and discount some of the real problems that women face in male violence, right? So, we … talked about why it might still be important [to take the train], what we’re going to keep an eye on … texting her parents if she feels uncomfortable, taking a phone call, carrying mace … things that were safety planning, rather than safety behaviors.” (Specialty Anxiety Clinic, Clinician 5) “I have a client right now where she and her mom believe in spirit guides, and she also talked about a fear of having a ghost in the house. And … disentangling … parts of that that might be an out of proportion fear. And … there may be things that are really legitimately scary that we wouldn’t target with exposure … I think about … what are the factors that might make somebody’s fears very different … than my assumption or my experience might be?” (Specialty Clinic, Clinician 4) |
Addressing environmental stressors and structural barriers | “I need to do my due diligence of making sure she does have access to food and care. So, it’s not … a situation where I would want to report her for neglect, because I knew Mom was working.” (Specialty Clinic, Clinician 1) “What’s been helpful is addressing the whole system, rather than just the individual … I spent a lot of time … coordinating care, so getting informants from school to give me data on what’s going on with youth, as well as any other pediatricians or religious leaders that could help me understand the nature of the impairment for the youth.” (Specialty Clinic, Clinician 7) “If there’s a caseworker on board, having them be part of it, or if the school is invested, having the school play a role in monitoring exposures or providing support. Definitely creating space for it in session too … And I think just in general, shoring up support resources, and not putting everything just on the caregiver, but thinking about the broader system that can support families.” (Specialty Clinic, Clinician 2) “I try to see [about] … the local English-speaking class for free, especially, or maybe they have some church … groups for people.” (Generalist Clinic, Clinician 11) | |
Therapeutic Phase: Culturally responsive treatment delivery and process | ||
Theme 3: Aligning Ex-CBT techniques with client values and cultural traditions | “With grief work, I found that taking that into account … what do they usually do, maybe it’s something that’s not really common in America … and then figuring out how we can bring some of that into their life … how to incorporate their traditions that they might have not been able to engage in.” (Generalist Clinic, Clinciain 14) “If I’m going to bring in a certain technique I do provide a lot of psychoeducation … and get a kind of feel of, like, okay, how can I truly adapt this? Is this area foreign, or it’s just not aligning with your culture …? So, just really being open to that as well … trying to … collaborate, to see how we can pick mini bits and pieces of this and … this other approach … it’s a trial and … we can always go back and try to see about another approach as well.” (Generalist Clinic, Clinician 8) “I was working with a Hispanic young woman, and in the cognitive restructuring portion, she talked about conflict with family and how it impacts her anxiety. And … they might have cultural expectations that would be considered enmeshed by some family therapists, and she was very anxious about feeling enmeshed for the rest of her life … So, in cognitive restructuring, we really had to … think about where we could be flexible but where it’s also important for her to meet some of her family’s expectations.” (Specialty Clinic, Clinician 5) “Being … thoughtful about what is the point of this intervention …? When I’m doing this intervention really well, does that align with the culture? … Cognitive restructuring challenge-based approaches may not always work as well with certain religions or cultures or family structures. And just being open and transparent, and if that doesn’t work, do we need to modify it or do we not need to use this thing because it doesn’t align with values?” (Specialty Clinic, Clinician 9) | |
Theme 4: Incorporating social identity into exposure planning | “I want to ignore what anxiety … is telling me, right? … But I don’t want to ignore cultural aspects of this person’s identity that might make an exposure hard or might make cognitive restructuring hard.” (Specialty Clinic, Clinician 5) “One kid [had] this fear of sticking out … at school. … I kind of pushed exposures on her in that direction with trying to … wear a dress you would wear for some kind of festive [event] … but have limited yourself from wearing because of this fear of sticking out … Her hair is not straight and blonde, and so she didn’t want to show it off … and we kind of did some things around that, which also kind of helped.” (Specialty Clinic, Clinician 1) “Recognizing that time … is one of the hardest resources to come by, especially for families of low SES. … So rather than having a contrived exposure, for example, like getting a sense of what their typical routine looks like, and how can we build exposure so that it doesn’t add burden to the family … and same with rewards … how can we make it work within the family resources, which includes time and parent energy? … And … our exposures often are requiring children to go into the community, but that may not be safe, depending on where the child lives.” (Specialty Clinic, Clinician 2) | |
Theme 5: Engaging in collaborative decision-making and flexibility | “I do believe clients are the experts of their own life. And really taking cues from them. So, when it comes to treatment goals, really asking them what is your goal? What would it look like for them? … Not just, like, oh, if you’re saying you want to do X, Y, and Z, this is my interpretation of how it should look like in your life. Maybe that’s going to look different.” (Generalist Clinic, Clinician 8) “I would … ask them, like, what do you actually want to work on? So, at least it gives them the autonomy to … decide … And then, usually … I’ll bring up the techniques I used to work with clients in the past. But I also will tell them, sometimes it works with people, sometimes it doesn’t … because everyone’s different … So, I would ask them, how do you feel if you try this? … So, that’s how we end up doing the treatment plan.” (General Community Mental Health Clinic, Clinician 10) “Approaching everything with an attitude of curiosity and not … assuming that a certain strategy or approach is going to work for a family or system, but really trying to … be really exploratory, both with respect to families’ resources and capabilities, and values and attitudes. And … continually modeling … [a] willingness to be collaborative and shift.” (Specialty Anxiety Clinic, Clinician 2) | |
Theme 6: Building trust | Building trust through self-disclosure | “Sometimes I use a little bit of self-disclosure about … [being an] immigrant … So, it’s helpful for them because it doesn’t feel like I see myself as a person with authoritarian role, but someone that’s equal with them … Sometimes I self-disclose about my experiences with anxiety, but I don’t go very detail about it … I’ll explain, like, I used to struggle with anxiety, and so, it helps them to know that … they’re not the only ones feeling that.” (Generalist Clinic, Clinician 10) “I was working with a Black family, and they had just transferred to me from another woman of color, I would make sure in the first session … to point out your previous therapist was a woman of color and I’m a White man. There’s definitely a difference in level of trust and level of privilege, and I just want to know how you guys feel about [it].” (Specialty Clinic, Clinician 5) “I acknowledge … my own identity as being a heterosexual White woman who doesn’t completely share their experience of the world …. I really try not to put the onus on them to teach me about it … I think there are some cases of very specific things where having a therapist who shares that experience, specifically, might be important. But … I’m willing to say, this is my experience, this is my lens, this is what I can offer. Hopefully, I’m the right person to help you with it. And if I’m not, I’ll find someone who is.” (Specialty Clinic, Clinician 4) “I have a client who is experiencing a very difficult family dynamic that I also went through for most of my life, and I wanted her to know she wasn’t alone in that … So, I shared that with her and … helped to validate her experience and provide her with some hope about her ability to overcome it … I think that when you can find common ground it’s a great opportunity to build rapport.” (Generalist Clinic, Clinician 16) |
Building trust through recognition and validation of negative experiences | “Being open and clear with them that I understand … [that] you learned to do these things, because your environment is unsafe, you’ve seen things … Once they feel heard … they start to be more open to working on it.” (Generalist Clinic, Clinician 14) “I was in a much better place to … collect information about … their values, or their racial identity … once they had established that I was in their corner … If I was willing to sort of work against some of the systems that were working against them and advocate for the family … it was then helpful for me to learn more about the family because that trust was there.” (Specialty Clinic, Clinician 2) | |
Building trust takes time | “People … have had negative experiences with the consistency of the provider … parents not hearing from the provider … I found it creates a sense of mystery, distrust, not understanding what’s happening …. So, I found that consistency and transparency has been the best … motivator for building trust … It takes time for somebody to realize, like, okay, this isn’t changing. It’s a stable kind of professional relationship. It’s transparent.” (Generalist Clinic, Clinician 14) “Some kids have lived on the streets for the entirety of their lives and have no family members at their disposal … And I’m aware that, due to the nature of the trauma that our kids have experienced in their lives, sometimes a trusting relationship … may take a prolonged period of time, or sometimes it may happen instantly … or never.” (General Community Mental Health Clinic, Clinician 12) “There’s clients where rapport-building comes with just spending more time getting to know them. And then there’s other clients that are in real distress, and they’re not going to trust you until you show you can help them.” (Specialty Anxiety Clinic, Clinician 2) | |
Theme 7: Engaging in self-reflection as a tool to improve cultural responsiveness | “And once you enter the therapy room … examining your own bias … and then being thoughtful [that] … all aspects of your conceptualization and treatment are driven by the intersectionality of their various cultural identities. So, not pathologizing, but … using that as a way that understands and appreciate … their culture.” (Specialty Clinic, Clinician 9) “I want to be aware of the fact that there were differences between us … it’s always in the back of my mind … is there something that we’re disconnecting on? Is there a way that we can connect?” (Specialty Clinic, Clinician 1) “When I … have these conversations with clients, reflecting both before and after with my supervisor, how it went, and then depending on the client situation, I may even process in conversation with the client depending on their presenting problem.” (Specialty Clinic, Clinician 9) “And I think just also learning from missteps … being open about when you made a mistake in learning about a client and … being willing to be wrong and show that you’re a person too, that makes mistakes. And that I’m not above that or unapologetic but being open to … learning.” (Specialty Clinic, Clinician 2) |
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© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
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Flowers, S.N.; Sanchez, A.L.; Siddiqui, A.; Weiss, M.; Becker-Haimes, E.M. Clinician-Reported Person-Centered Culturally Responsive Practices for Youth with OCD and Anxiety. Children 2025, 12, 1034. https://doi.org/10.3390/children12081034
Flowers SN, Sanchez AL, Siddiqui A, Weiss M, Becker-Haimes EM. Clinician-Reported Person-Centered Culturally Responsive Practices for Youth with OCD and Anxiety. Children. 2025; 12(8):1034. https://doi.org/10.3390/children12081034
Chicago/Turabian StyleFlowers, Sasha N., Amanda L. Sanchez, Asiya Siddiqui, Michal Weiss, and Emily M. Becker-Haimes. 2025. "Clinician-Reported Person-Centered Culturally Responsive Practices for Youth with OCD and Anxiety" Children 12, no. 8: 1034. https://doi.org/10.3390/children12081034
APA StyleFlowers, S. N., Sanchez, A. L., Siddiqui, A., Weiss, M., & Becker-Haimes, E. M. (2025). Clinician-Reported Person-Centered Culturally Responsive Practices for Youth with OCD and Anxiety. Children, 12(8), 1034. https://doi.org/10.3390/children12081034