Atlas›Domain XV · Nature, philosophy, social & rites of passage›Guide 076
Guide XV-076

Culturally adapted and decolonial therapies

Bernal, Bonilla, Bellido, Hwang1995
A 39 · L 46 · M 1525 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Bernal, Bonilla and Bellido's (1995) eight-dimension ecological validity framework for adapting treatments; Hwang's (2009) Formative Method for Adapting Psychotherapy (FMAP) as Aguirre, Spector and Orrell (2014) summarise and apply it; the DSM-5-TR Cultural Formulation Interview (CFI) as the American Psychiatric Association publishes it; Tervalon and Murray-García's (1998) cultural humility as the clinician's stance; and decolonial practice as described for Mullan's Decolonizing Therapy (Norton, 2023), Duran's Healing the Soul Wound (2nd ed., Teachers College Press, 2019) and Linklater's Decolonizing Trauma Work (Fernwood, 2014), using the publishers' descriptions of these books (as carried by booksellers) and NPR reporting on practitioners. The book texts themselves are not quoted here; details beyond those descriptions are marked [uncertain] or [synthesis].

This is a family of frameworks and stances, not a single manualised therapy. Two traditions sit together here. Culturally adapted therapy takes an existing evidence-based treatment and changes it, systematically, so that it fits a client's language, values, context and community. Bernal and colleagues argue that a treatment fitted this way has greater ecological validity, and their framework names eight dimensions to adapt: language, persons, metaphors, content, concepts, goals, methods and context [source: Bernal, Bonilla & Bellido 1995, Springer abstract]. Hall and colleagues separate top-down adaptation (an existing treatment modified for a new group) from bottom-up development (a treatment built from within the group) [source: Hall et al. 2016]. Decolonial therapy goes further. In Mullan's framing, all therapy is political, colonial, historical and intergenerational trauma shape mental health and its treatment, and clinicians trained in Eurocentric models must look at both the privileged and the oppressed parts of themselves [source: publisher's description of Mullan 2023]. Duran writes from clinical work in Indian country. He treats the client as having a relationship with their physical, mental or spiritual problem, frames intergenerational trauma and internalised oppression as the colonial "soul wound", and puts Western therapeutic metaphors into Indigenous terms [source: publisher's description of Duran 2019]. Linklater centres Indigenous concepts of wellness and wholistic health, drawing on a dialogue with ten Indigenous health practitioners, and critiques psychiatric diagnosis [source: publisher's description of Linklater 2014].

How change happens: in both traditions, a treatment works better and engages people more when it makes sense in the client's own cultural terms and names the structural and historical causes of suffering, rather than placing those causes only inside the person. Change runs through a relationship in which the clinician owns their own position and power [source: Tervalon & Murray-García 1998; Mullan 2023 description; synthesis].

Evidence status (one line, as the reviews state it): across 78 studies, a meta-analysis found culturally adapted interventions outperformed other conditions (g = 0.67). Against the same unadapted intervention the advantage was medium (g = 0.52), but only nine studies made that comparison [source: Hall et al. 2016]. A systematic review of adapted CBT for Latin American patients questioned whether adaptation is always needed, and stressed clinician training and individual tailoring [source: Hernandez Hernandez, Waller & Hardy 2020].

Where this sits: this guide is placed with social repair and justice practices because decolonial work treats repair of collective and historical harm as part of healing. Cross-refer V 137 (liberation psychology) and V 180–182 (Indigenous and culturally grounded community healing) for community-level and ceremony-based healing led by communities themselves.

2. Framework

The sources give no fixed session count or phase timetable for individual therapy, so none is stated here [uncertain]. The phases below combine the CFI sequence, Bernal's dimensions and the decolonial stance into a working order for one clinician. The ordering is [synthesis] unless a source is tagged.

Phase 0: Clinician preparation (before and throughout). Goal: examine your own cultural position, power and training biases. Cultural humility is described as "a lifelong commitment to self-evaluation and self-critique" [source: Tervalon & Murray-García 1998]. Mullan asks Eurocentrically trained clinicians to look at both their privileged and their oppressed parts [source: Mullan 2023 description]. Move on: you never finish this phase. It continues in supervision alongside every later phase.

Phase 1: Engagement and cultural assessment (early sessions). Goal: understand the problem in the client's own terms and context. Format: the 16-question core CFI, in seven sections: cultural definition of the problem; causes; stressors and supports; role of cultural identity; self-coping, past help-seeking and barriers; current preferences; and the clinician–patient relationship. Add supplementary modules where relevant, for example Explanatory Model, Social Network, Religion and Spirituality, Immigrants and Refugees, Children and Adolescents, Older Adults, Caregivers and Psychosocial Stressors [source: APA DSM-5-TR CFI]. Broach race, ethnicity and culture explicitly [source: Day-Vines, Routledge description]. Move on when you can state the problem in the client's own words, their explanatory model, their key supports and stressors (including discrimination), and what help they want.

Phase 2: Culturally and historically informed formulation. Goal: a shared account that places personal difficulties within family, community, historical and structural contexts, including intergenerational trauma and internalised oppression where the client recognises them [source: Duran 2019 description; Mullan 2023 description]. Identify community-specific sources of risk and resilience [source: Hall et al. 2016 recommendations]. Move on when the client agrees with the formulation, or has amended it, and it points towards goals.

Phase 3: Choosing and adapting the treatment. Goal: decide what evidence-based or culturally grounded approach to use, and what to change across Bernal's eight dimensions [source: Bernal et al. 1995]. Decide whether the changes are peripheral (engagement, delivery, therapy framework) or core (adding, modifying or replacing a component) [source: Chu & Leino 2017 as summarised in Hernandez Hernandez et al. 2020]. Base each change on this individual's needs rather than on ethnicity alone [source: Hernandez Hernandez et al. 2020]. Move on when the client has agreed a plan and its rationale makes sense to them.

Phase 4: Delivery with continuous review of fit. Goal: deliver the adapted treatment. Keep the components that make it work while keeping cultural fit [source: Hall et al. 2016 on fidelity and fit]. Return to the clinician–patient relationship question (CFI section 7) and repair cultural ruptures [source: APA CFI; Day-Vines, Routledge description, chapter on cultural ruptures]. Move on when goals are met, or the plan is revised.

Phase 5: Collaboration, community and ending. Goal: link the client with family, community, religious or traditional resources they choose. Collaborate with traditional healers or Indigenous helpers if the client wishes. Plan endings that keep those connections [source: CFI past help-seeking and preferences; Linklater 2014 description; synthesis].

Programme-level track (FMAP), for services adapting a group or manualised programme [source: Hwang 2009 as summarised by Aguirre et al. 2014]:

  1. Generate knowledge and collaborate with stakeholders (participants, health workers, community organisations, religious groups), usually through focus groups.
  2. Integrate what stakeholders said with theory, evidence and clinical knowledge, then draft an adapted manual.
  3. Review and revise with stakeholders and the planned facilitators; translate.
  4. Test in a pilot for feasibility and effects.
  5. Synthesise participant and facilitator feedback and finalise the manual.

Move to each next phase when that phase's product exists: stakeholder input, a draft, a revised draft, pilot data.

3. Guiding principles

  • Cultural humility over "competence" as an endpoint. In practice: you treat yourself as someone always learning about this client's culture from the client, and you never certify yourself as finished [source: Tervalon & Murray-García 1998].
  • Redress power imbalances. In practice: name your role and power, invite the client to correct you, and share decisions about goals and methods [source: Tervalon & Murray-García 1998].
  • Nonpaternalistic partnership with communities. In practice: work with community organisations and leaders as partners, not as referral targets or research sites [source: Tervalon & Murray-García 1998; FMAP stakeholder phase, Aguirre et al. 2014].
  • Therapy is political. In practice: you ask how colonial, historical and current oppression bear on the presenting problem, and you examine how your own practice may take part in oppression [source: Mullan 2023 description].
  • Ecological validity. In practice: check each part of the treatment (language, persons, metaphors, content, concepts, goals, methods, context) for fit with the client's world [source: Bernal et al. 1995].
  • Substantive adaptation over surface matching. In practice: translation or ethnic matching alone is not adaptation. Change cultural content and values where the formulation calls for it [source: Hall et al. 2016 recommendations].
  • Balance fidelity with fit. In practice: keep the active components of an evidence-based treatment, and change how they are delivered and framed; rigid fidelity can limit effectiveness [source: Hall et al. 2016].
  • Individualise; avoid assumptions based on ethnicity. In practice: adapt because this client needs it, not because of their group. Consider acculturation and the disorder; beware "broken leg exceptions" [source: Hernandez Hernandez et al. 2020].
  • The client's own terms come first. In practice: use the client's word for the problem in later questions and in the formulation [source: APA CFI interviewer instructions].
  • Assessment tools inform, not decide. In practice: the CFI supports understanding and decisions and is not the sole basis for a diagnosis [source: APA CFI].
  • Relationship with the problem. In practice: you can explore how the client relates to their difficulty (and how it relates to them), as well as reducing symptoms [source: Duran 2019 description].
  • Wholistic wellness and caution about diagnosis. In practice: assess physical, emotional, mental, spiritual, relational and community dimensions, and hold diagnoses as tools rather than identities [source: Linklater 2014 description; synthesis].
  • Culture as strength, not only wound. In practice: look for intergenerational strengths, belonging and joy as well as harm [source: NPR 2022 reporting on decolonial practitioners].
  • Voluntariness. In practice: the client decides how far to explore heritage, ancestry, religion or historical trauma; cultural material is offered, never required [synthesis].
  • Cultural authority stays with communities. In practice: Indigenous ceremonies and traditional healing are led by those with authority in that community; a clinician without that standing does not run them. Duran includes in each chapter a section to help non-Indigenous counsellors apply his ideas in culturally sensitive ways [source: Duran 2019 description; synthesis].
  • Ethics of multiple relationships. In practice: in small or close-knit communities, and when collaborating with community leaders, follow APA Ethics Code Standard 3.05 on multiple relationships, and record your reasoning [source: APA Ethics Code; synthesis].

Spiritual or religious difficulty: where the clinical focus is a client's religious or spiritual problem (for example, conflict over a tradition, or loss of faith after displacement), DSM-5-TR's "Religious or Spiritual Problem" may be recorded under ICD-10-CM Z65.8 "Other specified problems related to psychosocial circumstances", which lists religious or spiritual problem under its Includes notes [source: ICD-10-CM Z65.8 (Unbound Medicine)]. The exact DSM-5-TR wording is [uncertain: not verified].

4. Intervention inventory

The sources describe frameworks, an interview and stances more than step-by-step techniques. Steps below follow the named source's structure; the session-level wording and sequencing are [synthesis] unless tagged. CFI question wording is copyrighted: the sections are named and paraphrased here. Clinicians may reproduce the published form unmodified for use with their own patients [source: APA DSM-5-TR CFI].

4.1 Clinician cultural self-examination

  • Purpose / when: before you take on clients from communities other than your own, and again whenever you notice a strong reaction, defensiveness or assumption. Rooted in cultural humility's "lifelong commitment to self-evaluation and self-critique" [source: Tervalon & Murray-García 1998] and Mullan's call to recognise both your privileged and your oppressed parts [source: Mullan 2023 description].
  • Steps: (1) Write out your own cultural, class, racial, religious, migration and language positions, and your family's history with colonisation, displacement or being the dominant group. (2) List the models you were trained in and whose experience they were built on. (3) For a current client, note what you assume about them and where that assumption comes from. (4) Name one way your service or method may reproduce oppression for this client, such as cost, language, diagnosis, or location. (5) Take items 3 and 4 to supervision or a consultation group, ideally with someone from, or knowledgeable about, the client's community [synthesis].
  • Example language (illustrative, to a supervisor): "I notice I keep framing her family's involvement as enmeshment. I want to check whether that's my training talking."
  • Watch for: guilt that turns into over-apologising to clients, or into avoiding the topic; treating self-examination as a one-off training box ticked. It is working when your formulations include context you would previously have missed, and when clients correct you more freely [synthesis].

4.2 Introducing the cultural assessment

  • Purpose / when: at intake, or when cultural factors surface later. The CFI opens with an introduction that frames the interview as an effort to understand the person's experience and ideas [source: APA DSM-5-TR CFI].
  • Steps: (1) Explain in your own words that you want to understand the problem as the client sees it, including family, community and background, and that there are no right answers. (2) Say they can skip any question. (3) Agree whether an interpreter or family member will join, and on the client's terms (see 4.16). (4) Go on to the CFI sections in order, or weave them into a conversational intake [synthesis on flexibility].
  • Example language (illustrative): "People make sense of problems like this in very different ways, depending on their family, community and background. I'd like to hear how you see it, in your own words. If any question doesn't fit, tell me and we'll skip it."
  • Watch for: suspicion that the questions are a test, or a way of categorising the client; clients who have had past bad experiences with services. Working: the client starts using their own idioms and stories rather than clinical terms [synthesis].

4.3 Cultural definition of the problem (CFI section 1)

  • Purpose / when: first substantive step of assessment. Elicits the client's description of the problem, how they explain it to the people around them, and what troubles them most about it. Related modules: Explanatory Model; Level of Functioning [source: APA DSM-5-TR CFI].
  • Steps: (1) Ask what brings them, in their words. (2) Ask how they would describe it to family or friends. (3) Ask what bothers them most. (4) Write down their exact term (for example, a word for nerves, spirit, stress or a family matter) and use it from then on; the CFI instructs interviewers to use the person's own term in later questions [source: APA CFI interviewer instructions].
  • Example language (illustrative): "You called it 'the heaviness'. When you talk to your sister about the heaviness, what do you tell her it is?"
  • Watch for: replacing the client's term with a diagnosis too early. Working: the client recognises their own language in your summary [synthesis].

4.4 Explanatory model: causes (CFI section 2, causes)

  • Purpose / when: to learn the client's theory of cause and their network's theory, which may differ (for example spiritual, moral, social, physical or historical). Related modules: Explanatory Model, Social Network, Older Adults [source: APA DSM-5-TR CFI].
  • Steps: (1) Ask why they think this is happening. (2) Ask what others in family or community think causes it. (3) Reflect back both views without ranking them. (4) Note where the explanations differ, as these differences are often sources of family conflict and of help-seeking choices [synthesis].
  • Example language (illustrative): "So for you this started after the move, and your mother thinks it's something left unresolved from your grandfather's time. Both of those matter for how we work on it."
  • Watch for: dismissing spiritual or supernatural explanations, or endorsing them as fact. Hold them as the client's and the community's understanding [synthesis]. Working: the client offers more of their explanatory world over time.

4.5 Stressors, supports and discrimination (CFI section 2, stressors and supports)

  • Purpose / when: to identify what helps and what worsens the problem, including relationships, work, school and discrimination. Related modules include Social Network, Caregivers, Psychosocial Stressors, and Religion and Spirituality [source: APA DSM-5-TR CFI].
  • Steps: (1) Ask what makes it better and what makes it worse. (2) Ask directly about discrimination or unfair treatment because of background or identity, since many clients will not raise it unasked [synthesis]. (3) Map supports: family, faith community, elders, friends, community organisations. (4) Note structural stressors such as housing, immigration status, poverty and policing, as part of the problem rather than background [source: NPR 2022 on naming external oppression; synthesis].
  • Example language (illustrative): "Some people find that being treated differently because of their background, at work or anywhere else, is part of what's weighing on them. Has anything like that been part of this for you?"
  • Watch for: the client minimising discrimination to protect you, or because they expect disbelief. Working: they bring examples later without being asked [synthesis].

4.6 Exploring cultural identity (CFI section 3)

  • Purpose / when: to understand which aspects of background or identity (such as ethnicity, religion, language, migration, gender, sexuality, class or disability) help or harm, and whether identity creates other difficulties. Related modules include Cultural Identity, Immigrants and Refugees, and Children and Adolescents [source: APA DSM-5-TR CFI].
  • Steps: (1) Ask what about their background or identity matters most to them. (2) Ask whether any of it makes the problem better or worse. (3) Tailor the follow-up questions to the identities they named; the CFI instructs this for its identity items [source: APA CFI interviewer instructions]. (4) Explore intersections, such as being LGBTQ+ within a religious family, or disabled within a community that stigmatises disability [synthesis].
  • Example language (illustrative): "You mentioned being the first in your family born here, and being Muslim. Which of those, if either, feels most part of what you're going through?"
  • Watch for: assigning an identity the client did not claim. Working: the client describes identity as layered and changing, rather than giving you a label [synthesis].

4.7 Coping, past help-seeking and barriers (CFI section 4)

  • Purpose / when: to find out what the client has done on their own, every source of help they have used (including traditional and spiritual healers, religious leaders and family remedies) and what was useful, and what barriers they faced, such as cost, stigma or a lack of services in their language [source: APA DSM-5-TR CFI].
  • Steps: (1) Ask what they have tried themselves. (2) Ask about every kind of help, naming traditional, religious and community options so the client knows these are acceptable to mention. (3) Ask what helped and what did not. (4) Ask what has made getting help hard. (5) Note any helper the client may want you to coordinate with (see 4.21).
  • Example language (illustrative): "Besides doctors or counsellors, some people see a priest, an imam, a healer or an elder, or use remedies from home. Have you tried anything like that, and did it help?"
  • Watch for: the client hiding traditional help-seeking for fear of judgement; barriers that you or your service create (fees, hours, location, forms). Working: the client discloses parallel help, and you can plan around it [synthesis].

4.8 Current preferences and the clinician–patient relationship (CFI sections 5 and 6)

  • Purpose / when: at the end of the CFI, and again at review points. Asks what help the person wants now, what their social network recommends, and whether there are concerns about the clinic or clinician, such as perceived racism, language barriers or cultural differences, and what would address them [source: APA DSM-5-TR CFI].
  • Steps: (1) Ask what kind of help they hope for. (2) Ask what family or community think they should do. (3) Ask, plainly, whether anything about you or the service might get in the way, including your background, and what would help. (4) Act on at least one answer visibly, for example a change of interpreter, time, venue or involvement of family [synthesis].
  • Example language (illustrative): "I'm a white therapist and you've told me some of the people who hurt you looked like me. If that gets in the way here, I want to know, and we can talk about what would help, including a referral."
  • Watch for: polite reassurance that hides discomfort. Revisit later. Working: the client raises concerns about the relationship spontaneously [synthesis].

4.9 Supplementary CFI modules and the religious or spiritual focus

  • Purpose / when: when a theme from the core CFI needs depth. The APA lists supplementary modules beside each core section, including Explanatory Model, Level of Functioning, Social Network, Psychosocial Stressors, Religion and Spirituality, Cultural Identity, Immigrants and Refugees, Children and Adolescents, Older Adults and Caregivers [source: APA DSM-5-TR CFI]. The modules' contents are [uncertain: not verified].
  • Steps: (1) Pick the one or two modules most relevant to the formulation. (2) Use them across sessions rather than as one long interview [synthesis]. (3) Where the clinical focus is a religious or spiritual problem, consider the Z65.8 code (Section 3) and the Religion and Spirituality module. (4) With a migrant or refugee client, screen for trauma and current safety before going into migration history in detail [synthesis].
  • Example language (illustrative): "You've said your faith used to hold you up and now it feels far away. Could we spend some time on what your faith has meant to you and what's changed?"
  • Watch for: module fatigue; distress when going into migration or persecution history. Working: the formulation gains specific, usable detail [synthesis].

4.10 Broaching race, ethnicity and culture

  • Purpose / when: early in therapy and whenever relevant. Day-Vines defines broaching as the provider discussing the contextual dimensions of race, ethnicity and culture during counselling. Her framework includes a continuum of broaching behaviour, a multidimensional model, and a stage for preparing and delivering a broaching statement [source: Day-Vines, Routledge description]. A dissertation study found that avoiding these topics harmed the counselling relationship [source: Zegley 2007]. The names of the continuum's styles are [uncertain: not verified].
  • Steps: (1) Prepare: decide what difference or similarity between you and the client is likely to matter, and why now [source: Day-Vines "preparation and delivery" stage, outlined; synthesis on content]. (2) Deliver a short, open statement naming the dimension and inviting the client's view. (3) Accept any answer, including "it doesn't matter". (4) Return to it when the client's material touches race, ethnicity or culture, rather than only once. (5) If the client feels stereotyped by it, repair it (4.24).
  • Example language (illustrative): "We come from different backgrounds. You're Black and I'm South Asian. I wonder whether that difference, or race more generally, has any bearing on what you're dealing with, or on how it feels to talk to me."
  • Watch for: broaching as a ritual line delivered once; or pressing when the client has declined. Working: race and culture become ordinary topics the client brings in [synthesis].

4.11 Culturally and historically informed formulation

  • Purpose / when: after assessment. Places the problem within personal, family, community, historical and structural contexts. It draws on Duran's attention to intergenerational trauma and internalised oppression [source: Duran 2019 description], Mullan's centring of colonial and historical trauma [source: Mullan 2023 description], and Hall et al.'s recommendation to identify community-specific risk and resilience [source: Hall et al. 2016].
  • Steps: (1) Draw a layered map with the client: individual (symptoms, history); family (several generations where known); community (belonging, conflict, faith); historical (colonisation, enslavement, displacement, genocide, war, as relevant to this client's lineage); and structural (current discrimination, poverty, immigration law). (2) Ask which layers feel most connected to the problem. (3) Add strengths at each layer. (4) Write a short shared summary in the client's words, using their term for the problem. (5) Revisit as therapy goes on [synthesis on the map format].
  • Example language (illustrative): "When we put it all on one page, your panic isn't only about you. It sits next to your family having to leave everything twice, and the way you're treated at work now. And here's what got your family through: your grandmother's stubbornness, the church, each other."
  • Watch for: imposing a historical-trauma story the client does not recognise; overwhelm when historical atrocity is named (titrate; see Section 5). Working: the client reports less self-blame and more sense of context [synthesis].

4.12 Distinguishing structural oppression from internalised oppression

  • Purpose / when: when self-criticism, shame or low self-worth may reflect taken-in messages from oppression. A decolonial therapist profiled by NPR described examining workplace discrimination rather than framing the problem only as low self-esteem, and noted that self-feeling "can also be internalized oppression" [source: NPR 2022]. Duran names internalised oppression as a problem his case material addresses [source: Duran 2019 description].
  • Steps: (1) Gather a specific self-critical belief. (2) Ask where the client first heard or learned it: family, school, media, institutions. (3) Ask whose interests the belief serves. (4) Separate what is a response to real external injustice, which you validate and may plan action on, from a belief that has been taken in and can be questioned. (5) Link to agency: community, advocacy, or boundaries [synthesis].
  • Example language (illustrative): "'I'm not professional enough.' Where did you first hear that, and who was it said about? Let's look at what's actually happening in those meetings, and separately at the voice that agrees with it."
  • Watch for: turning all distress into oppression, which can miss treatable conditions; or the opposite, cognitive restructuring of accurate perceptions of discrimination. Working: the client can tell injustice they face apart from beliefs they carry [synthesis].

4.13 Exploring family and ancestral history

  • Purpose / when: when intergenerational patterns, migration, colonisation or historical violence may bear on the problem. A decolonial therapist profiled by NPR helps clients of colour understand how their ancestors' oppression affects them today [source: NPR 2022]. Mullan's book addresses intergenerational legacies [source: Mullan 2023 description].
  • Steps: (1) Ask permission to explore family history, and agree a stop signal. (2) Build a genogram, or a family story map if the client prefers, adding migrations, losses, community events and what was never spoken about. (3) Ask what was passed down: rules, silences, skills, faith, foods, language. (4) Ask what the client wants to keep, and what they want to put down. (5) Where records are lost (as through enslavement, residential schools, adoption or war), treat not knowing as part of the story, and do not press the client to fill the gaps [synthesis].
  • Example language (illustrative): "Your grandmother never talked about the years before the camp. What do you think that silence taught the family?"
  • Watch for: retraumatisation, especially where family members were victims or perpetrators of violence; conflict with living relatives; grief for lost language or land. Working: the client sees patterns with compassion rather than blame [synthesis].

4.14 Working with the client's relationship to the problem

  • Purpose / when: when a problem such as substance use, rage or despair is experienced as a presence or force, or as inherited. Duran's model treats patients as having a relationship with their physical, mental or spiritual problems [source: Duran 2019 description]. How Duran conducts this in session is [uncertain: not verified]. The steps below are [synthesis] in the spirit of that description.
  • Steps: (1) Invite the client to describe the problem as if it had a character: when it arrived, what it wants, what it gives and what it takes. (2) Ask how their family or tradition would name or understand it. (3) Explore what a different relationship with it would look like: respect, negotiation, separation. (4) Link to concrete changes in behaviour and support.
  • Example language (illustrative): "If the drinking were someone who came into your family three generations ago, what would you say to it now?"
  • Watch for: framing a medical risk (such as alcohol withdrawal, psychosis or suicidality) only in symbolic terms. Keep medical assessment and safety planning running in parallel. Working: the client feels more agency and less shame [synthesis].

4.15 Adapting language and metaphors (Bernal: language, metaphors)

  • Purpose / when: whenever therapy terms, materials or examples do not land. Language covers delivering treatment in the client's preferred language and idiom. Metaphors covers using symbols, sayings and concepts shared by the client's group [source: Bernal et al. 1995 dimensions; definitions paraphrased, detail [uncertain]]. Duran describes rendering Western therapeutic metaphors in Indigenous terms [source: Duran 2019 description].
  • Steps: (1) Ask the client which language they think and feel in for this topic; offer therapy, or parts of it, in that language, or with a trained interpreter. (2) Collect the client's own sayings, proverbs, stories or religious images that bear on the problem. (3) Re-express the treatment's key ideas (for example, the link between thoughts and feelings, or exposure) using those images, after checking them with the client. (4) Translate written materials properly; translation and validation of measures are a separate task from adapting the therapy [source: Hernandez Hernandez et al. 2020].
  • Example language (illustrative): "You said your father used to say 'the river doesn't push back at the stone, it goes around.' Could that be a way to think about these worry thoughts?"
  • Watch for: borrowing sacred imagery the client did not offer; clumsy translations. Working: the client starts using the shared metaphor themselves [synthesis].

4.16 Adapting persons and context (Bernal: persons, context)

  • Purpose / when: when who delivers therapy, who is present, or where and how it happens affects engagement. Persons concerns the client–therapist relationship and cultural similarities and differences. Context concerns the client's broader social, economic and political circumstances, such as acculturation and migration [source: Bernal et al. 1995 dimensions; details [uncertain]]. Hall et al. found that therapist–client ethnic match did not significantly moderate outcomes [source: Hall et al. 2016].
  • Steps: (1) Ask whether the client prefers a therapist of a particular background or gender, and offer referral where one is available, without assuming they want a match. (2) Agree who attends: family, a support person, an interpreter. (3) Adjust the setting: community venue, home, telehealth, times that fit work or prayer. Aguirre et al. report changing session structure for travel distances, farm seasons and rainy-season access, and avoiding venues that would make participants feel treated as sick [source: Aguirre et al. 2014]. (4) Address practical barriers such as fees, transport and childcare.
  • Example language (illustrative): "Would it help to meet at the community centre rather than the clinic? Some people find it easier."
  • Watch for: interpreters who are family members or known in the community (confidentiality, and sometimes coercion); venues where the client may be seen. Working: attendance and engagement improve [synthesis].

4.17 Adapting content, concepts and goals (Bernal: content, concepts, goals)

  • Purpose / when: when the treatment's theory, examples or targets clash with the client's values. Content covers cultural knowledge, values and traditions; concepts covers how the treatment model is framed so that it fits the client's culture; goals covers agreeing goals that support adaptive values from the client's culture [source: Bernal et al. 1995 dimensions; details [uncertain]]. Hall et al. call for substantive modifications to cultural content and values, not minor changes [source: Hall et al. 2016].
  • Steps: (1) Identify where the model's assumptions may clash. Examples: individual autonomy against family interdependence, emotional expression against restraint, "assertiveness" against respect for elders. (2) Discuss the clash openly with the client. (3) Reframe goals in terms the client values, for example "keeping family harmony while saying what I need" rather than "assertiveness". (4) Replace examples and exercises with ones from the client's life and culture. (5) Keep the treatment's active ingredient, for example behavioural activation's link between activity and mood [synthesis].
  • Example language (illustrative): "The usual worksheet talks about 'putting yourself first'. That doesn't sound like you or your family. How would you put the goal so it fits how you want to live?"
  • Watch for: adapting goals so far that they reinforce a harmful or coercive family pattern. Check that goals serve the client, not only the family. Working: homework is done, and goals feel like the client's own [synthesis].

4.18 Adapting methods, and deciding core versus peripheral changes

  • Purpose / when: when planning the adapted treatment. Methods covers procedures adjusted to the client's culture, such as more or less directive styles, group versus individual work, or written versus oral homework [source: Bernal et al. 1995 dimensions; detail [uncertain]]. Chu and Leino classify adaptations as peripheral (engagement: access, retention, psychoeducation; delivery: materials, language, cultural examples; therapy framework: session structure, provider–client relationship, person and place) or core (adding, modifying or replacing a component) [source: Chu & Leino 2017 as summarised in Hernandez Hernandez et al. 2020].
  • Steps: (1) List the planned changes. (2) Label each one peripheral or core. (3) For each core change, name the active ingredient you are keeping or replacing, and why. (4) Write the adaptations into the notes so they can be reviewed [source: Hernandez Hernandez et al. 2020, call to define adaptations clearly]. (5) Review against outcome (4.23).
  • Example language (illustrative, to the client): "The usual approach uses daily written records. You've said writing isn't how you work, so we'll use voice notes. The important part, noticing what happened and how you felt, stays the same."
  • Watch for: drift, where the "adaptation" quietly drops the effective component; and adaptations made because of the client's ethnicity rather than their stated needs. Working: you can explain each change and the outcome supports it [synthesis].

4.19 Involving family

  • Purpose / when: when family is central to the client's world, or to the problem. A decolonial therapist profiled by NPR often brings parents into sessions to hear their perspectives on immigrant and intergenerational experience [source: NPR 2022]. The CFI asks about the social network's view and recommendations [source: APA DSM-5-TR CFI].
  • Steps: (1) Ask the client whether, whom and why; respect a refusal. (2) Agree beforehand what will and will not be shared. (3) In the joint session, invite each person's story, especially the elders' accounts of migration or hardship. (4) Help the generations hear each other's frames. (5) Debrief with the client alone [synthesis].
  • Example language (illustrative, to a parent): "Your daughter has told me a little about how hard the first years here were. Would you be willing to tell us what it was like for you?"
  • Watch for: coercion, family violence, forced-marriage risk, or LGBTQ+ safety. Do not hold joint sessions where these exist, and follow safeguarding and legal duties. Watch also for elders' re-traumatisation. Working: there is more mutual understanding and less conflict [synthesis].

4.20 Building on cultural strengths

  • Purpose / when: throughout, to balance trauma-focused work. A decolonial practitioner profiled by NPR works with clients to see their culture as a source of intergenerational strength, and emphasises reconnecting with cultural background and with community [source: NPR 2022].
  • Steps: (1) Ask what in the client's background has helped them or their family survive. (2) Identify practices they have lost touch with and would like back: language, music, food, faith, land-based activity, community events. (3) Plan small, concrete steps of reconnection, chosen by the client. (4) Notice the joy and belonging these bring, and record it in the formulation [synthesis].
  • Example language (illustrative): "When you talk about cooking with your aunties, your whole voice changes. What would it take to have more of that in your life?"
  • Watch for: romanticising a culture, or pushing reconnection on a client who has good reasons for distance, such as abuse in the community, or rejection over sexuality. Working: more support and meaning [synthesis].

4.21 Collaborating with traditional healers, religious leaders and community helpers

  • Purpose / when: when the client already uses, or wants, such help. The CFI asks about traditional and spiritual help-seeking [source: APA DSM-5-TR CFI]. Linklater builds her book on a dialogue with Indigenous health practitioners [source: Linklater 2014 description]. FMAP treats religious groups and community organisations as stakeholders [source: Aguirre et al. 2014].
  • Steps: (1) Get the client's explicit written consent for any contact, specifying what may be shared. (2) Approach the helper respectfully, as a fellow helper; ask how they understand the problem and what they offer. (3) Agree on roles, and on how to flag risk. (4) Never direct or evaluate ceremony; cultural authority stays with the community [synthesis]. (5) Keep medical and risk care in place. Do not advise the client to stop any medicine or treatment. (6) Follow APA Ethics Code Standard 3.05 if you are in the same community or take part in shared events [source: APA Ethics Code; synthesis].
  • Example language (illustrative, to an elder): "She's told me your guidance matters a lot to her. I'd like to understand how you see what she's going through, and how we can work so we're not pulling her in different directions."
  • Watch for: practices that are harmful (for Domain XVI practices, cross-refer and follow safeguarding), helpers who discourage needed medical care, or exploitative fees. Working: the client experiences consistent, joined-up support [synthesis].

4.22 Adapting a programme with FMAP (service level)

  • Purpose / when: when a service adapts a manualised group or programme for a community. Use the five FMAP phases [source: Hwang 2009 as summarised by Aguirre et al. 2014].
  • Steps: (1) Identify and invite stakeholders: participants, health workers, community organisations, religious groups. Run focus groups. (2) Combine their input with theory, evidence and clinical knowledge into a draft adapted manual. (3) Have stakeholders and the planned facilitators review it; revise; translate with expert translators. (4) Pilot it and record feasibility and effects. Aguirre et al. report replacing unsuitable activities with familiar local ones (such as a traditional word game), and limiting reading and writing where literacy was expected to be low. (5) Collect feedback from participants and facilitators and finalise the manual. Aguirre et al. added comfort and hospitality elements, and advised facilitators to ask questions sensitively.
  • Example language (illustrative, to a focus group): "This programme was written somewhere very different. We need your help to know what will feel strange, what's missing, and what would make people want to come back."
  • Watch for: token consultation; community members' time going unpaid; losing core components. Working: stakeholders recognise the final version as theirs, and pilot uptake is good [synthesis].

4.23 Monitoring fit and outcome

  • Purpose / when: throughout delivery. Hall et al. recommend culture-specific outcome measures, noting that most studies relied on standard instruments [source: Hall et al. 2016].
  • Steps: (1) Agree with the client one or two outcomes in their own terms, such as "able to attend family gatherings" or "the heaviness less often", and rate them regularly. (2) Use standard measures too, choosing validated translations where they exist. (3) Ask about fit at review points: what is working, what feels foreign. (4) Adjust the adaptation and record why [synthesis].
  • Example language (illustrative): "On a scale you choose, how much has 'the heaviness' got in the way this week?"
  • Watch for: measures with no validated translation, and scores that may underestimate or overestimate distress in this group; the client's wish to please. Working: the client's ratings and the standard measures broadly agree on change [synthesis].

4.24 Repairing cultural ruptures

  • Purpose / when: after a microaggression, a stereotyping comment, a misreading of the client's culture, or a broach that went badly. Day-Vines's book has a chapter on cultural ruptures [source: Day-Vines, Routledge description]; its content is [uncertain: not verified]. The CFI's relationship section invites these concerns [source: APA DSM-5-TR CFI].
  • Steps: (1) Notice markers: withdrawal, sudden politeness, missed sessions, a flat reply after your remark. (2) Name the moment and take responsibility without defending your intent. (3) Invite the client's experience and listen without correcting. (4) Say what you will do differently. (5) Check in at the next session. (6) Take it to supervision [synthesis].
  • Example language (illustrative): "Last week I assumed your family would object to you moving out. You went quiet after that. I think I put my assumption onto you, and I'm sorry. What was that like for you?"
  • Watch for: asking the client to educate you or comfort you; over-apology. Working: the alliance deepens after the repair, and the client raises such moments sooner next time [synthesis].

4.25 Purposeful therapist transparency

  • Purpose / when: when shared or contrasting history is relevant, and disclosure serves the client. A decolonial therapist profiled by NPR shares some of her own intergenerational trauma and avoids the detached-expert role, describing herself as part of "collective healing" with clients [source: NPR 2022].
  • Steps: (1) Before disclosing, ask yourself whose need it serves. (2) Keep it brief and relevant. (3) Return the focus to the client. (4) Notice the effect, and ask about it [synthesis].
  • Example language (illustrative): "My own family also lost its language within two generations, so I know a little of what that grief can be like. What's it like for you?"
  • Watch for: disclosure that burdens the client, makes your story the centre, or blurs boundaries. In small communities, consider Standard 3.05. Working: the client feels less alone and keeps the focus on their own material [synthesis].

5. Handling problems

The sources say little about specific clinical difficulties. Except where tagged, the guidance below is [synthesis].

  • The client does not want culture, race or history discussed. Respect it. Say once that the door stays open, and continue with the treatment the client chose. Some clients come for symptom relief, and broaching that keeps pressing becomes another imposition. Avoidance is linked with relationship harm [source: Zegley 2007], but voluntariness comes first. Revisit only when the client's own material raises it.
  • The client experiences adaptation as stereotyping ("you're treating me as my ethnicity"). Apologise and repair (4.24). Ask which changes help and which do not, and remove the unwanted ones. Base adaptations on this person's needs, acculturation and disorder rather than on group membership [source: Hernandez Hernandez et al. 2020].
  • Overwhelm or retraumatisation when exploring historical, colonial or family trauma. Slow down. Return to present-day stabilisation and grounding. Name that remembering collective atrocity can bring up grief and rage that are proportionate, not pathological. Shift to strengths (4.20). Break the work into small pieces. Agree a stop signal before any historical exploration. If the client has PTSD symptoms, use an evidence-based trauma treatment, culturally adapted, with its own safety steps, and do not use historical exploration in place of it.
  • Despair, hopelessness or suicidality linked to oppression. Assess risk with standard current practice and make a safety plan. Lethal-means counselling covers storage and removal only. Validate the reality of injustice without letting it stand as proof that nothing can change. Link the client with community and advocacy. Crisis resources: 988 Suicide & Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland). Where available, offer culturally specific crisis lines.
  • Stuck: the formulation names oppression but nothing changes. Check that the work still has concrete goals and keeps the treatment's active components [source: Hall et al. 2016 on fidelity and fit]. Add action: community connection, advocacy, rights advice, workplace grievance support. Review whether a symptom-focused treatment, such as for depression, anxiety or substance use, is being left out.
  • Disagreement about diagnosis. A client or community may reject a psychiatric label. Linklater critiques psychiatric diagnosis [source: Linklater 2014 description]. Explain what a diagnosis would and would not mean, including access to services. Record the client's own term for the problem alongside it. The CFI is not meant to be the sole basis for a diagnosis [source: APA DSM-5-TR CFI].
  • The client wants traditional or ceremonial healing you cannot provide. Do not attempt it. Help the client reach legitimate community sources, coordinate with their consent (4.21), and cross-refer V 180–182. For a ceremony with documented harm, cross-refer the relevant harm accounts, such as XI 094.
  • Conflict between a cultural practice and safety. Safeguarding and legal duties come first. These include forced or child marriage, family violence, coercive religious practice, and Domain XVI practices such as genital cutting, which are cross-referred and not described here. Cultural responsiveness never overrides child protection or adult safeguarding. Explain your duties to the client in advance where you can.
  • Family or community pressure against therapy, or against the client's choices (for example sexuality, divorce, leaving a faith). Explore the client's own wishes and their safety. Do not hold joint sessions where there is risk. Consider Z65.8 if the focus is religious or spiritual. Help the client weigh belonging against autonomy without deciding for them.
  • Interpreter difficulties. Use trained professional interpreters, not family. Brief them on confidentiality and on the therapy's aims. Check whether they come from the client's community or a rival one. Debrief them after distressing sessions.
  • Non-adherence to homework. Ask whether the task fits the client's life, literacy, time, space and values. Adapt the method (4.18): oral instead of written, a family-based rather than solitary task, faith-compatible timing. Keep the purpose of the task.
  • Clinician guilt, defensiveness or over-identification. Clinicians from the dominant group may over-apologise or avoid challenge. Clinicians from the client's own community may assume shared experience, or be drawn into community roles. Use supervision and consultation, keep up the lifelong self-examination that cultural humility describes [source: Tervalon & Murray-García 1998], and apply Standard 3.05 to overlapping relationships.
  • Political disagreement in the room. Some clients will not share a decolonial framing. Offer it as one lens, never as a belief the client must hold. Mullan holds that therapy is inherently political [source: Mullan 2023 description]; the client still decides what their own experience means.
  • Service or protocol constraints (fixed manuals, session caps, measures in one language). Make the peripheral adaptations you are allowed to make, and document them. Raise structural barriers with the service. Propose FMAP-style stakeholder input for programme revisions [source: Aguirre et al. 2014].
  • Rupture around the therapist's identity. Use CFI section 6 and 4.24. Offer a referral to a therapist of another background if the client wants one, without treating it as failure.

Sources

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