January 2024Original Research: Culturally Adapted Cognitive Behaviour Therapy (CaCBT)

Culturally Adapted Cognitive Behaviour Therapy (CaCBT) to Improve Community Mental Health Services for Canadians of South Asian Origin: A Qualitative StudyLa Thérapie cognitivo-comportementale culturellement adaptée (TCCCa) pour améliorer les services de santé mentale communautaires à l’intention des Canadiens d’origine sud-asiatique : une étude qualitativeFarooq Naeem, MBBS, MSc, FRCPsych, PhD¹, Nagina Khan, BHSc, PGCert, PhD²

, Nazia Sohani, MSc³, Farhana Safa, RSW, MBBS, MPH, MScCH⁴, Mehreen Masud, MACP, RCC⁵, Sarah Ahmed, MSc⁶, Gary Thandi, MSW, RSW⁷, Baldev Mutta, SSW⁸, Azaad Kasaam, MD FRCPC⁹, Kamlesh Tello, MSc¹⁰, Muhammad Ishrat Husain, MBBS, MD(Res.), MRCPsych¹

, Muhammad Omair Husain, MBBS, MRCPsych¹, Sean A. Kidd, PhD, CPsych¹

and Kwame McKenzie, BM, FRCPysch¹img1

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie
2024, Vol. 69(1) 54-68
© The Author(s) 2023
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/07067437231178958
TheCJP.ca | LaRCP.caimg2

AbstractBackground: South Asian (SA) Canadians are disproportionately affected by higher rates of mood and anxiety disorders. SA Canadians with depression report significant barriers to accessing mental health care and the highest proportion of unmet mental health needs. The Mental Health Commission of Canada (MHCC) advocates for culturally and linguistically relevant services for SA Canadians. Culturally adapted cognitive behavior therapy (CaCBT) has shown to be more effective than standard cognitive behavior therapy (CBT). Adapting CBT for the growing SA population in Canada will ensure equitable access to effective, culturally-appropriate mental health interventions.Method: The study used a qualitative design to elicit stakeholder consultation via in-depth interviews. This study is reported using the criteria included in Consolidated Criteria for Reporting Qualitative Studies (COREQ). The analysis follows an ethnographic approach and was informed by the principles of emergent design.Results: Five themes were identified from the analysis, (i) Awareness and preparation: factors that impact the individual’s understanding of therapy and mental illness. (ii) Access and provision: SA Canadians’ perception of barriers, facilitators, and access to treatment. (iii) Assessment and engagement: experiences of receiving helpful treatment. (iv) Adjustments to therapy: modifications and suggestions to standard CBT. (v) Ideology and ambiguity: racism, immigration, discrimination, and other socio-political factors.Conclusions: Mainstream mental health services need to be culturally appropriate to better serve SA Canadians experiencing depression and anxiety. Services must understand the family dynamics, cultural values and socio-political factors that impact SA Canadians to reduce attrition rates in therapy.RésuméContexte: Les Canadiens sud-asiatiques (SA) sont affectés de façon disproportionnée par les taux plus élevés de troubles anxieux. Les Canadiens SA souffrant de dépression dénoncent des obstacles importants à l’accès aux soins de santé mentale et la proportion la plus élevée de besoins de santé mentale non comblés. La Commission de la santé mentale du Canada (CSMC) préconise des services culturellement et linguistiquement pertinents pour les Canadiens SA. La Thérapie cognitivo-comportementale culturellement adaptée (TCCCa) s’est révélée plus efficace que la thérapie cognitivo-comportementale (TCC) régulière. Adapter la TCC pour la population SA grandissante au Canada assurera un accès équitable à des interventions de santé mentale efficaces et culturellement appropriées.Méthode: La présente étude a utilisé une conception qualitative pour susciter la consultation des intervenants par des entrevues en profondeur. Cette étude est reconnue utiliser les critères inclus dans les Critères consolidés pour les rapports d’études qualitatives (CCREQ). L’analyse suit une approche ethnographique et était éclairée par les principes de la conception émergente.Résultats: Cinq thèmes se sont dégagés de l’analyse, (i) Facteurs de sensibilisation et de préparation qui influent sur la compréhension de la thérapie et de la maladie mentale. (ii) Accès et prestation : Perception des Canadiens SA sur les obstacles, les facilitateurs et l’accès au traitement. (iii) Accès et prestation : Perception des Canadiens SA sur les obstacles, les facilitateurs et l’accès au traitement. (iv) Ajustements thérapeutiques : modifications et suggestions de la TCC standard. (v) Idéologie et ambiguïté : racisme, immigration, discrimination et autres facteurs socio-politiques.Conclusions: Les services de santé mentale traditionnels doivent être culturellement adaptés pour mieux servir les Canadiens SA souffrant de dépression et d’anxiété. Les services doivent comprendre la dynamique familiale, les valeurs culturelles et les facteurs socio-politiques qui ont un effet sur les Canadiens SA afin de réduire les taux d’attrition en thérapie.Keywords
depression, anxiety, behavioral, culturally adapted CBT, CBT, South Asian, qualitative researchBackgroundSA origin are the largest racialized group in Canada. The three largest racialized groups in Canada represent 16.1% of Canada’s total population (SA: 2.6 million people; 7.1%; Chinese: 1.7 million; 4.7%; and Black individuals: 1.5 million; 4.3%), with each population topping 1 million.¹ In 2016, these groups represented 13.6% of Canada’s total population, which indicates the rapid population growth of visible minority groups in the country.² SA Canadians are disproportionately affected by higher rates of mood and anxiety disorders compared to Caucasian Canadians.³ In addition, SAs who immigrated to Canada at the age of 17 or younger experience higher anxiety and other psychological symptoms compared to individuals from elsewhere who immigrated to Canada at the same age.^4,5 Furthermore, Canadians of SA origin are significantly impacted by the social determinants of health, including unemployment, low income, language barriers, low education, low literacy and migration stress.¹ These factors can negatively impact mental health and decrease access to care, thereby increasing mental health inequities.⁶ Compared to other ethno-cultural groups, SA Canadians with a major depression report significant barriers to accessing mental health care (33%) and the highest proportion of unmet mental health care needs (48%).⁷ SA Canadians that experience major depression are 85% less likely to seek treatment than their White counterparts.⁶ The lower use of mental health services by SA Canadians indicate inequities in accessing appropriate care for these populations.^6-9 The MHCC recommends improving Canadian mental health care to serve diverse populations with equitable, timely access to appropriate, effective, and evidencebased treatments that meet unique sociocultural needs.^10,11 The MHCC Case for Diversity report highlights the necessity for culturally and linguistically appropriate services particularly for immigrant, refugee, ethno-cultural and racialized populations, including SA Canadians.^6,12CBT is considered the gold standard psychotherapy¹³ for the treatment of several mental health conditions and is endorsed by international treatment guidelines including National Institute for Health and Care Excellence (NICE) and American Psychological Association (APA).^14,15 The effectiveness of CaCBT has been tested in a Randomized Controlled Trial (RCT) targeting 50 Chinese American adults experiencing major depression.¹⁶ Completion of twelve sessions demonstrated a more significant decrease in depressive symptoms among CaCBT groups compared to standard CBT. Additionally, the dropout rate was lower when patients were receiving the culturally adapted CBT intervention in comparison to standard CBT.¹⁶Adaptation of therapy in many cultural setting is not a new phenomenon, as Interpersonal Psychotherapy (IPT) has been used with efficacy and effectiveness¹⁷ with many adaptations of IPT in various cultural settings.¹⁷ CBT in its available format does not always meet the needs of non-Western groups due to pre-existing differences in cultural values.^18-20 To address these issues, CBT needs to be culturally adapted for individuals who are from different ethnic backgrounds and needs to be established as an operational, evidence-based intervention.^21-25 CaCBT has shown to be more effective and has shown a reduction drop-out rates when compared with standard CBT.^16,26 CaCBT is crucial to increase access to mental healthcare and improve outcomes for immigrant, refugee, ethno-cultural, and racialized populations.^27-29 Adapting CBT for the growing SA population in Canada will ensure equitable access to effective, culturally-appropriate mental health interventions.The purpose of this study was to create a CaCBT manual for the SA Canadian population living with anxiety and depression. To culturally adapt CBT, and explore participants’ understanding of mental health, their experiences with mental illness, access to mental healthcare, and to elicit the recommendations to improve treatment for this group.MethodThis qualitative study is reported using the criteria included in Consolidated Criteria for Reporting Qualitative Studies (COREQ), a 32-item checklist reporting guidance for qualitative research.³⁰ COREQ checklist was used to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.³⁰ The analysis was undertaken using an ethnographic approach³¹ and informed by the principles of emergent design.³² The emergent design denotes the ability to acclimatize new ideas, conceptions, or results that ascend through conducting the research. The emergent approach is embedded within every stage from conception to publication.³² This method allowed for any unanticipated information to be generated, therefore contributing to the richness of the data.The aim of the study was to engage various stakeholders, living in the Greater Toronto Area (GTA) (municipalities of Halton, Peel, York, Toronto and Durham), Vancouver and Ottawa to inform the development of CaCBT guidelines for depression and anxiety, building on our research teams previously developed qualitative methodology.^33-36EthicsThis study was approved by the Centre for Addiction and Mental Health’s (CAMH) REB (#071/2019). All participants provided written informed consent to participate in the study.Data CollectionSemi-structured, in-depth interviews were conducted and the interviewees were encouraged to talk freely about specific predetermined topics.^37,38 This approach allowed the interviewers to pursue in-depth information on the topics of interest by asking or probing with follow-up questions to gain greater understanding of the cultural context and treatment.^37,38Eligible participants provided consent were then invited to participate in semi-structured interviews in the languages they were most comfortable speaking. Interviews lasted 30–60 min, they were conducted using videoconferencing software and were audio recorded. Field notes were taken during these sessions, noting non-verbal communication and behaviours to triangulate with the interview data.³⁹ NS, FS, and MM conducted semi-structured interviews using an interview guide for each target group (see in Appendix A). The three research assistants received regular supervision from the research team. Each interview recording was transcribed verbatim and checked for accuracy by the research team. A random selection of interviews was assessed by study principal investigator (FN) in the research team for transcription accuracy, themes were rechecked by NK.RecruitmentA purposive sampling method was used to recruit individuals from four different target groups through our partnering agencies within the target local community: (a) SA individuals with depression and/or anxiety, (b) caregivers and family members of SA individuals affected by depression and anxiety (c) mental health professionals’ and (d) SA community opinion leaders. Snowball sampling was used to facilitate recruitment and individuals selfidentified in the above groups.³⁷ Therefore, SA community opinion leaders could also include individuals that were professionals. Interested individuals were invited to complete an inclusion questionnaire to determine their eligibility to participate in the study. The inclusion criteria for the four groups are described below. Recruitment materials were developed in various SA languages to engage individuals whose first language was not English.Inclusion CriteriaSA Clients

Self-identification as SA or of SA origin,

Between the ages of 18–65, and currently diagnosed/previously diagnosed as having depression and/or anxiety or show the symptoms of these disorders.

Who identified as South Asian

Ages 18–64

Had access to an electronic device

A Hospital Anxiety and Depression Scale (HADS) score of 8 or higher

Caregivers and Family Members of SA Individuals Affected by Anxiety and Depression

Parents / relatives / guardians of a SA individual who had been diagnosed with depression and/or anxiety or had shown the symptoms of these disorders.

Mental Health Professionals

Mental health workers or clinicians who have worked directly with Canadian SA client populations who had been diagnosed with depression and/or anxiety or had shown the symptoms of these disorders.

MHP participants were Registered Psychotherapists, Registered Social Workers, Counsellors and Recreation Therapists.

SA Community Opinion Leaders

Self-identification as SA or of SA origin and are involved in Canadian SA communities.

Data AnalysisNVivo 12 software⁴⁰ was used to analyze the data. Identifying information was removed from the transcripts and was analyzed for systematic content and themes.⁴¹ The analysis was undertaken with the research team who collected the data and under supervision of the FN. The data was triangulated by comparing themes from different participant groups across sites.³⁹ The analysis was approached by making notes of first impressions and thoughts. For the initial analysis process, labels were created for codes that emerged. These came directly from the text and were used as the initial coding scheme. The codes were sorted into categories based on how different codes were related, overlapped, and linked. The evolving categories were used to organize and cluster codes into meaningful groups and final themes.^31,42ResultsForty-two participants were interviewed, which included thirteen individuals with depression and/or anxiety, nine caregivers and/or family members, ten community leaders and ten mental health professionals (MHPs). Sixteen participants were situated in Vancouver, twenty-one participants were interviewed from the Greater Toronto Area and five in Ottawa. Participant demographic data is summarized below (See Table 1).Using the emergent characteristic, which were an important part of the grounded theory, five themes were identified from the analysis (See Fig. 1), (i) Awareness and preparation: factors that impact the individual’s understanding of therapy and mental illness. (ii) Access and provision: SA Canadians’ perception of barriers, facilitators, and access to treatment. (iii) Assessment and engagement: experiences of receiving helpful treatment. (iv) Adjustments to therapy: modifications and suggestions to standard CBT (this included both individual and community level suggestions). (v) Ideology and ambiguity: racism, immigration, discrimination, and other socio-political factors that individuals’ felt they did not have control over but predisposed to mental health issues and illness.(i) Awareness and preparation: factors that impact the individual’s perception of therapy and mental illnessParticipants’ recognition and ownership of their own understanding of mental health included; experience of the signs, symptoms, causes and information about acceptable treatment options (Table 2). Our findings indicated that the family system played a major role in shaping the individual’s perception of mental ill health and the understanding around what was adequate treatment. Suggesting that a collectivistic approach might be more helpful and that the SA communities required services to include a role where the importance of a family unit was necessarily included because data showed this was intrinsically linked to and seen as a resilient part of their identity.(ii) Access and provision: SA Canadians’ perception of barriers, facilitators and access to treatmentThe theme ‘accessing treatment’ identified the barriers SA individuals had to face when in need of mental health services and treatment. The types of barriers that prevented access to treatment were related to immigration and settlement, financial difficulties, language and interpreters, poor level of acculturation and a lack of awareness about what mental health services could offer (see Table 3). Moreover, there were issues such as long waitlists for mental health treatments and lack of culturally competent services and/or therapists to really understand the SA trajectory and cultural context. Mental health services were further experienced as complex systems that were difficult to navigate.Financial resources:SA Canadians could not afford therapy as it was not covered under their medical health care plan. In cases where extended insurance was provided for therapy sessions, many noted that it was not sufficient to address their needs due to limited number of sessions offered. Findings indicate secrecy and denial existed of mental illness, to protect against stigma.Table 1. Participant Demographic Information.
Tab1“It’s expensive that’s for sure [laughs] it’s very expensive and unfortunately a lot of the South Asian population–for those who are coming to Canada especially they work in the laborlabor department you know like they–some of the work that they do it’s not a well-paid job so, if you’re charging-if you’re going to see a psychologist for CBT for your depression they’re probably going to charge you like a hundred dollars an hour or something right. So that can probably deter you from wanting to go seek treatment because it’s so expensive. And unfortunately, some of the registered psychotherapy is expensive when you go through like a private, when you try to seek it out privately. So it is expensive. Quite expensive actually” (Mental health professional, GTA)Language:Many participants found it difficult to express their needs in English. As noted by many participants, cultural nuances are lost in translation, and this made it difficult for many individuals to fully explain their mental health difficulties.“We have huge number of population here, here with us who don’t speak or read or write English language in South Asian community specially the parents those who are here. So I’ll appreciate if we can get something in Urdu, Hindi, Punjabi, the, the worksheets or anything, information, pamphlets, anything. I’ll really appreciate because most of my clients they, they – when we do CBT we cannot bring it, bring in CBT worksheets at all because of the language barrier. So I do provide therapy them in Urdu language and Hindi language, in Punjabi as well, so it’s all oral, and the homework, they cannot write anything because of the language barrier. But I give them still, you know, the, that open, and that, “okay, you can write on the plain paper what you’re thinking.” But still it is something in the language, oh wow, that will help our clients a lot. So this is another huge barrier.” (Mental health professional, GTA)fig1Table 2. Awareness and Recognition.
Tab2Table 3. Access and Provision.
Tab3Tab3aNeed for a translator:“People who are coming here English is not their first language, are not able to communicate with therapist unless the therapist speak their language. If they do communicate with the therapist they have to have a translator there. And if the translator’s there they might not feel comfortable sharing their most personal intimate details with a third person who – some, in most cases when a grandparent goes to a doctor they’re taking their grandchild with them or their kid with them, right? So they might not wanna share all those details if they have problems with their own family members, they’re not go and say that to a translator or their child who then tells the therapist what the problem is. You don’t know – so many messages are lost in translation that way.” (Community leader, GTA)(iii) Assessment and engagement: experience of receiving helpful treatmentPsychotherapists reported they applied therapies based on clients’ needs. All the interviewed therapists identified ‘active listening’ as a primary component while treating clients. The process involved open-ended questions, identifying clients’ negative thoughts and the changes clients want to see in their life, followed by goal setting, and finally, engaging the client in the care plan during therapy (see Table 4).(iv) Adjustments to therapy: modifications to standard CBTParticipants identified adjustments that would improve the overall therapy and for culturally appropriation, to improve its acceptability and impact. These included strategies MHPs had used affectively.What worked in therapy: Providers need to consider the collectivistic SA culture.“I think CBT, or just any types of therapy for it to be more effective I think they need to take like a cultural, cultural perspective with it and so like, a cultural perspective acknowledging that there’s like transgenerational trauma, and acknowledging that the trauma that your client has now it could be rooted from the trauma that their parents had, or, or, or what their grandparents had and that it can be passed down.” (Individual with depression/anxiety, Vancouver)Ineffective TechniquesParticipants identified techniques that were not culturally applicable for the SA community. Particularly, asking SA clients to go against their cultural beliefs and values for favorable results in therapy.“it’s really funny when like a counsellor tells me, “oh maybe you just need to put in boundaries with your parents” like that’s really hard to do with, with South Asian parents like putting boundaries [laughs] is hard with South Asian parents” (Individual with depression/anxiety, Vancouver)Table 4. Assessment and Engagement.
Tab4Tab4a“Like for a Southeast Asian woman, if you tell her, just like go party, enjoy yourself, go to a bar […] Or if you tell a Southeast man that from today you are going to cook, clean, do everything that your wife does, and that’ll make you happy, it’s not going to happen. So, you cannot modify the behaviour just because of their culture. Cognitive-behavioural therapy depends on modifying the behaviour of a person and if it is not culturally appropriate it will just not work.” (Community leader, GTA)(v) Ideology and ambiguity: racism, immigration, discrimination and other socio-political factors that individuals’ felt they did not have control over but made them susceptible to mental health issues and illness.Study participants cited socio-political factors that are beyond one’s control but nevertheless have a substantial impact on an individual’s identity, their role in society and their mental health (Table 5).DiscussionTo our knowledge this is the first study to qualitatively explore stakeholder attitudes and beliefs to inform cultural adaptation of CBT to the needs of the Canadian SA population. Our aim was to ultimately enhance the acceptability of CBT to the Canadian SA population to improve engagement and reduce health inequality. The present study was the first phase of a three-stage mixed methods trial of culturally adapted CBT. The qualitative research reported in this article is the analysis from phase one of a three-phased mixed-methods trial. The trial was the first mixed method study to investigate the need for a CaCBT intervention for the Canadian SA population to increase the value of CBT intervention in that group.The analysis of the forty-two interviews indicated that participants reported a lack of understanding from therapists because CBT did not include SA cultural values and norms, leading to implications that such clients could not access or engage with these treatments. For instance, Li et al., demonstrated that culturally adapted CBT for patients who were living with psychosis led to an increase in efficiency, accessibility, and acceptability of the therapy.³³ Forty-five semi structured interviews revealed the need for awareness of patients’ cultural and spiritual values, adaptation of language instead of simply translating verbatim, and adjustments in therapy, specifically, involvement of family in treatment approaches.³³ Anik et al., analyzed culturally adapted psychotherapies for depressed adults, looking at data on the process of adaptations using thematic analysis and treatment efficacy was assessed through meta-analysis of Randomized Controlled Trials. This study showed that culturally adapted psychotherapies were confirmed to be more efficacious than control treatments.⁴³There is still a gap existing in services to incorporate SA cultural values and norms into CBT therapies. Yet, our results point to the fact that if therapy is to be useful for these communities and for it to impact client outcomes positively, there is a dire need to include them in such interventions. This was an important finding that suggests that there is a need for CaCBT and is a key reason for why such interventions may likely have not worked in the past and prevented many SA clients from accessing treatments or help. While this is the first study that specifically focuses on the SA Canadian population, similar research shows that culturally adapting CBT to treat mental health conditions yields positive results in treating mental health conditions and improving retention to therapy for minority groups.^16,19,44,45Table 5. Ideology and Ambiguity.  Tab5Compared to a previous study which described the process of adaptation and the areas that need to be focused on to adapt CBT to a given culture, we found that racism, immigration, discrimination and other socio-political factors weighed heavily on the SA groups, causing direct and ‘consequential distress’ that individuals’ narrated as linked to having decreased control to change for positive outcomes.⁴⁶SA communities often rely on friends and family suggestions for what treatments are acceptable or useful. If there is a precedent set for an acceptable intervention within a community or family circle, then this acceptance/recommendation will be shared in the group. Participants suggested that educating family members and the general SA community to ‘brand’ the intervention ‘allowable,’ and for therapists and services to become familiar with the patients cultural and religious context could improve patients’ engagement in therapy. Therefore, working with a collectivist approach to include the ideas of family during engagement phase could increase the acceptability of interventions as they become familiar and can be endorsed by others in the family and community circles.Congruent with these findings, participants were highly aware that there was a sense of incompetency in service intervention for SA groups and overall a shortage of culturally appropriate services. They reported that accessing services that were operating in languages other than which they spoke was very difficult to navigate especially when there was already complexity around navigating complex health systems when the language wasn’t a barrier. Interventions that cannot be fully understood or carried out due to a lack of understanding, in both directions (from client to therapist and vice versa) were of little use or ineffective from the start to end. Where intervention could be useful, individuals reported financial costs as a barrier to accessing a therapist. Migration and low-income were the most prevalent and dominant factors that was linked to anxiety and depression in this group. Poverty in racialized communities is a growing problem in Canada. For example, 207,380 SA Canadians in Ontario live in poverty and that is approximately 18% of the SA population of Ontario.⁴⁷ Studies also show that racialized communities, including SA communities, are more likely to fall into poverty because of systemic barriers, such as racism.⁴⁷ Consequently, findings also alluded to therapists accepting their own inherent biases and sympathetically considering such factors that were beyond a clients’ control, and which was impacting their mental health negatively. They were also acutely aware of racism and cited socio-political factors suggesting helplessness as they were experienced as ‘beyond one’s control’ but still having a substantial impact on an individual’s identity, their role in society and their mental health.There are limited number of qualitative studies on CaCBT, however our findings are comparable with our previous qualitative studies conducted in different settings by our team. This research shows that CaCBT has a significant impact on improving therapeutic outcomes for Sa Canadians.^19,44,48 CaCBT has not been employed for SA Canadians formerly, our findings suggest that understanding patients’ cultural values and incorporating them in therapy is an effective treatment that can reduce dropout rates.Limitations and StrengthsA sample size of over 40 participants in the present study allowed for a rich set of data and content to analyze. Analysis of the transcripts revealed a repetition and consensus of themes across our four target groups, achieving cross validation from the groups. There were fewer male participants than females. There were also fewer participants from the Ottawa region, though the demographics of this region explain the number of South Asian individuals compared to Vancouver and the GTA. Our study was limited to the adult population and we did not capture data from the child, adolescent and senior populations, small urban or rural populations, Quebec and the Maritime Provinces, which may have distinct cultural and linguistic influences.Conclusions and Recommendations of Mental Health SupportThis study sought to demonstrate the usefulness of culturally adapted cognitive behavioural therapy (CaCBT) for SA populations living in Canada. Based on the findings of this research, we have recorded a number of considerations for providing mental health support for SA Canadians with depression and anxiety disorders, including the necessity of adaptations to existing CBT interventions in mental health services to meet the needs of diverse communities, see recommendations of support below.Recommendations of Support(i) Awareness and recognition: factors that impact the individual’s understanding of therapy and mental illness

More information to understand mental illness, such as depression and anxiety,

Services to work with the information that mental health among the SA population will be influenced by their family, sociocultural and religious values.

Take or integrate a collectivist approach that is tolerable to the SA communities, for example include the importance of the role of a family unit which was important to the individuals.

(ii) Increase access to treatment through working on factors related to immigration and settlement, financial difficulties, using appropriate language and interpreters, and increase awareness about what mental health services and interventions can offer.

Mental health treatments and services to move towards culturally competent services and/or where therapists can understand the SA trajectory and context.

Mental health services are experienced as complex systems that were difficult to navigate. For example, information regarding health systems navigation and their work would likely make individuals who might never hear of use a service, even if it was free or at subsidized cost access it.

(iii) Assessment and engagement: experience of receiving helpful treatment

Therapists to use “active listening” as a mechanism for understanding the client and their context.

Using open-ended questioning to identify clients’ negative thoughts. Eliciting the changes that clients want to see in their lives,

To use techniques to set achievable and context relevant goals, and

Engaging the client in the care plan during therapy.

(iv) Adjustments to therapy: modifications and suggestions to standard CBT

Providers to accept and work with the wider family of the individual using the service, by including the collectivistic SA culture.

Techniques that are not effective; therapist being aware not to request SA clients to undertake tasks that are not realistic and place them in conflict with their cultural beliefs and values for favorable results in therapy.

(v) Ideology and ambiguity:

Services to acknowledge racism, immigration, discrimination and other socio-political factors that made clients susceptible to mental health issues and mental illness,

Were experienced as not controlled or reduced with service intervention, as services took no responsibility to alleviate the distress and impact they had on mental health of SA clients

Important for therapists to understand intrinsic biases and consider factors that are beyond a patient’s control.

As Provinces and Territories are currently considering ways to expand access to publicly funded psychotherapies like CBT, both Ontario and Quebec have announced funding for structured psychotherapy programs, yet in both instances it is not clear how they plan to address issues of equity for immigrant, refugee, ethno-cultural or racialized (IRER) populations. This research has provided policy makers and service planners with evidencebased tools and a strong case for investment in the implementation of CaCBT for SA populations living in Canada.Abbreviations(CBT) Culturally adapted cognitive behaviour therapy(SA) South Asian(MHCC) The Mental Health Commission of Canada(COREQ) Consolidated Criteria for Reporting Qualitative Studies(NICE) National Institute for Health and Care Excellence(APA) American Psychological Association(RCT) Randomized Controlled Trial(GTA) Greater Toronto Area(CAMH) Centre for Addiction and Mental Health’s(HADS) Hospital Anxiety and Depression Scale(MHPs) Mental health professionalsAcknowledgementsWe extend our immense gratitude to the research participants who graciously shared their experiences and perspectives surrounding SA mental health through interviews. Their direct contributions have made the development of this work and this research possible. We would like to thank the Mental Health Commission of Canada, Somerset West Community Health Centre and Ottawa Newcomer Health Centre, Punjabi Community Health Services, and Moving Forward Family Services for their continual support. We would like to acknowledge Nina Flora for the organization, oversight and support during the data collection and analysis of this research. We also thank Bertina Jebanesan and Wishah Khan for their support in the organization of this research.Author ContributionsF.N, K.M, conceptualized the research question, design and methodology. F.N, K.M, supervised the group N.S, F.S, M.M and S.A. who acquired, analyzed and interpreted the data, with support from all authors. F.N provided supervision throughout. N.K. verified the analysis and interpreted the data, drafted the manuscript, with input and critical review from all authors. All authors read and approved the final manuscript.Data AvailabilityData are available on reasonable request.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.EthicsThis study was approved by the Centre for Addiction and Mental Health’s REB (#071/2019). All participants consented to participate in the study.FundingThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Health Canada.ORCID iDsNagina Khan

https://orcid.org/0000-0003-3870-2609Sean A. Kidd

https://orcid.org/0000-0002-2435-786XMuhammad Ishrat Husain

https://orcid.org/0000-0001-5771-5750Supplementary MaterialThe supplemental material for this article is available online.References

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¹ Department of Psychiatry, University of Toronto, Toronto, ON, Canada² Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada³ Immigrant Services, Ottawa Newcomer Health Centre, Ottawa, ON, Canada⁴ Punjabi Community Health Services, Brampton, ON, Canada⁵ Moving Forward Family Services, Surrey, BC, Canada⁶ Schizophrenia Division, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada⁷ Moving Forward Family Services, Vancouver, Canada⁸ Punjabi Community Health Services, Toronto, Canada⁹ Department of Psychiatry, University of Ottawa, Ottawa, Canada¹⁰ Access to Quality Mental Health Services, Mental Health Commission of Canada, Ottawa, ON, CanadaCorresponding Author:
Nagina Khan, Schizophrenia Division, Centre for Addiction and Mental Health, 33 Ursula Franklin St, Toronto, ON M5S 3M1.
Email: Nagina.Khan@camh.caJournal CoverOtsuka LundbeckEditorial BoardJournal InfoPerspective: A Call for an Evidence-Based Strategy Against the Overdose CrisisCommentary: The Burden of Psychosis in Black Communities in Canada: More than a Feeling,Original Research: Ten-Year Trends in Lithium Prescribing in Alberta, CanadaOriginal Research: The Association Between Prior Mental Health Service Utilization and RiskOriginal Research: Experiences of Sexual and Reproductive Health Care Access for WomenOriginal Research: Cost-Effectiveness of Group Transdiagnostic Cognitive BehaviouralOriginal Research: Culturally Adapted Cognitive Behaviour Therapy (CaCBT)Sage Peer ReviewersSage Author Services