The November BABCP Article of the Month is from the Cognitive Behaviour Therapist and is entitled “Cultural competency in the treatment of obsessive-compulsive disorder: practitioner guidelines” by Monnica T. Williams, Traleena M. Rouleau, Joseph T. La Torre and Noor Sharif.

The idea for the article originated with Dr. Monnica Williams and her work with the International OCD Foundation Diversity Advisory Council, which she co-founded. Dr. Williams is a Canada Research Chair at the University of Ottawa, School of Psychology, and Clinical Director at the Behavioral Wellness Clinic in Tolland, Connecticut. She has worked extensively with diverse clients with obsessive-compulsive disorder (OCD) and received clinical training from Dr. Edna Foa, a prominent researcher in treating anxiety disorders, early on in her career. She has published extensively on cross-cultural psychopathology, the delivery of culturally informed psychotherapy, and race-based trauma.

Dr. Williams noted that popular interventions for treating OCD such as Cognitive-behavioral Therapy (CBT) and Exposure and Ritual Prevention Therapy (Ex/RP) were limited in that they did not take into consideration the possible differences in how OCD may manifest for members of different ethnocultural groups. The article, based in a multiculturalist and anti-racist framework, highlights the fact that research studying ExRP for OCD has involved samples comprised almost entirely of non-Hispanic Whites/European Americans, and have tended to exclude sampling from diverse populations such as Black Americans, Jewish persons, Middle Easterners, Hispanics and South Americans, African communities, Indigenous persons, and Asian groups (Williams et al., 2010). This article attempts to contribute to filling in this knowledge gap by laying out practitioner guidelines for culturally competent OCD assessment and treatment as applied to diverse groups such as these.

Thus, the article came from two directions: the need to elucidate differences in how OCD manifests in diverse groups, and to highlight culturally appropriate approaches to treatment. As such some key competencies the article touches on includes awareness of clinician biases and knowledge gaps; stigma and mental health literacy; cultural variations in OCD symptom expression; the connection between discrimination on OCD; culturally-informed assessments for people of color with OCD; incorporating clients’ religious beliefs and culturally-predicated explanatory models of psychopathology into treatment; differentiating between normative religio-cultural practices and OCD; and designing culturally sensitive exposures.

Another major focus of the article is the role of religious beliefs in treating OCD. For example, it is not advisable for clinicians to exclude discussions of religion in treatment as this is often counterproductive (Leins & Williams, 2018). One lesser known subtype of OCD that people of color may experience is known as scrupulosity OCD, which features religious-themed obsessions. For clients such as these, exposure therapy is recommended, however the clinician must ensure that exposures are culturally appropriate and do not encourage committing sin (Williams & Wetterneck, 2019). When clinicians are working with diverse clients outside their area of expertise, it is recommended they consult with members of the client’s community such as clergy, friends, or family members to determine what form of treatment may be most appropriate.

Because many assessment tools for measuring OCD have been normed and validated on White samples, their use is extremely limited when working with diverse populations (e.g.,Thomas et al. 2000; Williams, Debreaux, & Jahn, 2016). The article also touches on this problem and provides several recommendations for clinicians when it comes to assessing OCD in clients of color. Other topics the article covers include differences in help-seeking behaviors, and barriers to treatment. We hope that clinicians will find the guidelines useful when approaching work with culturally diverse clients.

REFERENCES

Leins, C., & Williams, M. T. (2018). Using the Bible to facilitate treatment of religious obsessions in obsessive-compulsive disorder. Journal of Psychology and Christianity, 37(2), 112-124.

Thomas, J., Turkheimer, E., & Oltmanns, T.F. (2000). Psychometric analysis of racial differences on the Maudsley Obsessional Compulsive Inventory. Assessment, 7(3), 247-258. https://doi.org/10.1177/107319110000700305

Williams, M. T., Debreaux, M., & Jahn, M. (2016). African Americans with obsessive-compulsive disorder: An update. Current Psychiatry Reviews, 12(2), 109-114. doi: 10.2174/1573400512666160602124146

Williams, M. T., Powers, M. B., Yun, Y-G., & Foa, E. B. (2010). Minority participation in randomized controlled trials for obsessive-compulsive disorder. Journal of Anxiety Disorders, 24(2), 171-177. https://doi.org/10.1016/j.janxdis.2009.11.004

Williams, M. T. & Wetterneck, C. T. (2019). Sexual Obsessions in Obsessive-Compulsive Disorder: A Step-by-Step, Definitive Guide to Understanding, Diagnosis, and Treatment. Oxford University Press. ISBN: 9780190624798. doi: 10.1093/med-psych/9780190624798.001.0001

From Richard Thwaites, the Editor-in-Chief of tCBT: Why I chose this article:

When we published the Special Issue of tCBT looking at cultural adaptations of CBT in 2018, we were surprised by the massive amount of interest and sharing of the papers on social media. Since then I have become aware of the fantastic work of Monnica Williams and her team over in Canada and I was personally excited when she submitted this paper to tCBT given my interest in both OCD and cultural adaptations. This paper talks clinicians through the assessment and treatment of OCD and the changes that may be needed for ethnoracially minoritized groups. We are lucky in England to have the IAPT programme with its high levels of data completeness, sadly this data this tells us that in terms of both access and outcomes, many racialised  groups are doing much worse than the white population. Papers such as these are invaluable in providing guidance on how we can improve and serve the whole population equally.