Open access peer-reviewed chapter - ONLINE FIRST

Mindfulness-Based Stress Reduction as a Culturally Relevant Treatment for Racial or Ethnic Minorities

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Tiffany Williams, Esther Lynch, Paigean Jones, Jeffery Bass and Rhea Harrison

Submitted: December 19th, 2021 Reviewed: February 24th, 2022 Published: April 29th, 2022

DOI: 10.5772/intechopen.103911

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Counseling and Therapy - Recent Developments in Theories and Concepts Edited by Kenjiro Fukao

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Counseling and Therapy - Recent Developments in Theories and Concepts [Working Title]

Dr. Kenjiro Fukao

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Abstract

Racial or ethnic minorities (REM) are at a particularly high risk of experiencing mental health conditions. Unlike their White counterparts, social determinants of health (e.g., poverty, racialized violence, or discrimination) exacerbate REM quality of life. REM are less likely than non-Hispanic Whites to seek and receive mental health treatment. Additionally, REM are more likely to experience systemic barriers (e.g., cultural mistrust, stigma, lack of access, and financial barriers), which further complicates their willingness and capacity to seek treatment. While Evidence-Based Treatments (EBTs) are identified as empirically supportive treatments for a range of mental health conditions, there is skepticism about their cultural appropriateness and relevance for REM populations. Clinicians must be culturally competent and use clinical tools (e.g., Multidimensional Model for Developing Cultural Competence) to assist in promoting cultural competence. Likewise, practitioners must be conscientious and knowledgeable about the pitfalls of EBTs when working with REM. Mindfulness-based techniques, such as MBSR, are culturally sensitive and inclusive of historical, social, and cultural ideologies that align with the needs of REM. MBSR has the potential to offer holistic coping given its effectiveness in promoting neurological, physical, and psychological healing.

Keywords

  • racial or ethnic minorities
  • mental health
  • mindfulness-based stress reduction
  • social determinants of health
  • systemic barriers to treatment engagement

1. Introduction

Racial or ethnic minorities (REM) in the United States (US) are particularly vulnerable to experiencing mental illness. The US Census Bureau describes the term “race” as people who identify as “White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, or Other Race” and ethnicity as “Hispanic or Latino or “Not Hispanic or Latino.” [1]. While REM report the lowest lifetime risk of mental illness and fewer psychological concerns as compared to non-Hispanic Whites, they are more likely to experience persistent illness [2]. For example, experiences of depression among Blacks and Hispanics are reported as lower than Whites, yet Blacks and Hispanics indicate more persistent symptomatology. In a 2020 screening for most prevalent mental health concerns of Americans (n= 2.6 million), the data reflect notable changes for all people, but particularly, Asian or Pacific Islanders, Black or African Americans, and Native Americans have the highest change in searching for resources and increases in mental health conditions (e.g., depression, anxiety, and suicidal ideation) [3, 4].

Social determinants of health (e.g., health disparities, racial discrimination, racialized violence) exacerbate REM’s experiences of mental illness as well as their access to treatment and services [2, 3, 5, 7]. REM are also least likely to access culturally competent care and when they do seek the treatment they are improperly assessed, misdiagnosed, and receive poor care [6, 7, 8]. And thus, when REM seek treatment it is essential that counselors are culturally competent and use culturally appropriate interventions. Practitioners are trained and encouraged to utilize evidence-based treatments (EBTs), demonstrated in eliciting therapeutic change in providing care and treatment to their clients [9]. The cultural relevance of EBTs is debated and prescriptive clinical practice is criticized; some practitioners argue for more inclusive and culturally sensitive use of EBTs [10, 11]. Like most EBTs, the efficacy of mindfulness-based interventions has been investigated primarily on White people. Mindfulness-Based Stress Reduction (MBSR) is an evidence-based intervention shown to reduce stress for a few REM groups [12, 13]. A culturally adapted MBSR program has the potential to treat REM suffering from mental health conditions and improve quality of life.

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2. Prevalence of mental illness among REM

REM are particularly vulnerable to experiencing mental health conditions. In the year 2020, about 331.4 million people live in the US and the racial or ethnic statistics show a composition where 61.6% identify as White, 18.7% as Hispanic or Latino/a, 12.4% as Black or African American, 10.2% as two or more races, 6% as Asian, 1.1% as American Indian/Alaska Native, and 0.2% as Native Hawaiian/Other Pacific Islander [1]. Though there are more people who identify as White than all REM groups combined, research suggests that REM are at a significantly higher risk of experiencing mental health conditions in part due to the impact of social determinants of health [8, 14].

2.1 Hispanics or Latino/as

The Hispanic or Latino population differs in ethnicity and culture, which makes this population unique. Skin tones vary considerably, and it is not uncommon for non-Hispanic or -Latino/a people to confuse someone of Hispanic descent, as being White American or African American. Because of the significant differences, it is important to understand that while all Hispanics may encounter mental health disparities some groups of Hispanics are affected at even greater rates than others. Overall little difference in the prevalence of mental health disorders exists between Hispanic or Latinos/as and non-Hispanic Whites. One major issue Hispanic children grapple with is suicidality. Hispanic youth are more likely to consider, plan, and attempt suicide than both Black and White youth [15]. However, when comparing Hispanics born in the US with Hispanics who identify as foreign-born, the data shows that US-born Hispanics experience mental health disorders more frequently [16]. As seen many times in the marginalized populations, Hispanics are not likely to seek therapy due to lack of access, resources, stigma, and discrimination and if they do seek therapy, it is often when their condition is at its worst [17, 18]. Instead of seeking treatment, Hispanics are more likely to adopt unhealthy coping behaviors (e.g., excessive alcohol consumption, poor eating habits, smoking, and illicit drugs), which affect the body negatively and can lead to serious and life-threatening medical conditions [18, 19].

2.2 Black or African Americans

Black or African Americans suffer from mental health conditions at about the same rate as Whites. However, they consistently are misdiagnosed and underexamined due to culturally incompetent practitioners, and thus left untreated [20]. In fact, Black or African Americans are less likely than White Americans to seek counseling or treatment and more likely to struggle including persistent emotional distress with feelings that life requires too much effort, worthlessness, hopelessness, and despair [21]. Furthermore, the report of somatic or physical complaints is common for Black people, as is, often failing to recognize that the underlying cause of their complaints is likely connected to an untreated or undiagnosed mental illness. Like Hispanics, Black or African Americans are not likely to seek treatment and when they do, the condition is severe or in crisis and may require intensive treatment (e.g., hospitalization) [6]. Only one in three Black or African Americans who need mental health treatment will obtain it. Undoubtedly, apprehension to seeking treatments likely influences the prevalence of depression that exists among Black or African Americans. For some, depression is accompanied by suicidal thoughts. As of 2019, the 2nd leading cause of death among Black or African Americans between ages 15 and 24 is suicide. Poverty is a social determinant that exacerbates the prevalence of mental illness and impacts access to treatment. For Black Americans, living below poverty increases the risk of experiencing serious psychological distress at three times a higher rate than when not living in poverty. Lastly, because Black or African Americans are relentless targets of violent crimes, discrimination, and racialized violence, the likelihood of developing a traumatic stress disorder is higher than the general population [21].

2.3 Asians or Asian Americans

Asians are a diverse group that includes many distinct cultures, nationalities, diverse countries of origin, and mental health challenges. Asian Americans and Pacific Islanders comprise about 6.1% of the US population and of that nearly 15% reported experiencing a mental illness in the last year [22]. According to the American Psychological Association, Asian Americans are less prone than White Americans to seek help for any mental health or emotional concerns they experience [23]. Attempting and completing suicide is a prevalent issue within the Asian community and is identified as the 10th leading cause of death for Asian Americans. Women between the ages of 15 and 24 as well as 65 and older have the highest suicides rates across all racial and ethnic groups [24]. Asian Americans reported the increased vulnerability to mental health conditions are due to a range of factors including parental pressure to excel academically, discrimination, cultural attitudes as it relates to mental health care, difficulty with balancing cultures, and difficulty developing their sense of self while navigating multiple cultures [25]. Social determinants of health that exacerbate mental health conditions include discrimination, prejudice, racialized violence, problems related to immigration, cultural trauma, and model minority myth/stereotypes [22, 26]. Systemic barriers that serve as obstacles to treatment include misdiagnoses or under-diagnosing due to culturally incompetent practitioners, lack of multilingual services in healthcare, poor access to health insurance, and treatment costs [22, 26]. Because talking about mental health concerns are usually considered taboo, it is more likely for Asian American to seek support within their personal network.

2.4 American Indians or Alaskan Natives

Though American Indians and Alaskan Natives only make up 1.3% of the US population, over 19% indicated experiencing a mental health condition in the last year [27]. In fact, they report experiences of psychological distress at a rate of 1.5 times higher than all other racial groups. Historically, American Indians survived systemic trauma, such as forced relocation and family separation, death by way of war, and sickness and death due to exposure to infectious diseases, which likely impacts their mental health as well [28]. American Indians and Alaskan Natives have a substantially higher rate than the other racial or ethnic groups of experiencing post-traumatic stress disorder, suicide, substance use disorder, and attachment disorders [29]. Children and adolescents have the highest rates of suicidality as those between ages 15-19 have double the death rate than non-Hispanic Whites [27]. Furthermore, American Indians and Alaskan Natives use and abuse substances at younger ages and at higher rates than all other racial groups [7]. Major depression episodes and self-reported depression are three times higher than the US population. Additionally, American Indians and Alaskan Natives are still dealing with the consequences of past trauma and current detrimental policies as well as other social determinants, such as high poverty (e.g., 26.6% live in poverty), and other irreversible setbacks [27]. American Indians and Alaskan Natives are also twice as likely to experience unemployment their White counterparts. The cultural mistrust that exists is understandable yet has a negative effect on seeking mental health treatment, which in turn significantly increases the risk of mental illness. Systemic barriers that affect help-seeking include poverty rate, lack of access due to distance and language barriers, and lack of health insurances coverage [29].

2.5 Native Hawaiians and Pacific Islanders

Native Hawaiians and Pacific Islanders are yet another marginalized group that experienced historical trauma and are still coping as well as healing from the effects of the trauma today. The extent of the mental health disparity for this marginalized group is understudied, and thus, the prevalence of mental illness is a work in progress [26]. What is known is 10.1 % of Native Hawaiians and Pacific Islanders reported experiencing psychological distress as compared to 12.7% of non-Hispanic Whites. The leading cause of death between the ages of 15–24 among Native Hawaiians and Pacific Islanders was suicide in 2019 [30, 31]. Social determinants that exacerbate mental illness include multigenerational trauma, discrimination, poverty, housing inequities, and disparities in education and social capital [30, 31]. Like the other racial groups, there are several systemic barriers that exist to serve as an obstacle in receiving mental health treatment. One of the main barriers include the lack of access to care and health insurance [30]. In fact, Native Hawaiians and Pacific Islanders are three times less likely than non-Hispanic Whites to receive mental health services as well as prescriptions that treat psychological disorders. Although Native Hawaiian and Pacific Islanders do not report serious psychological distress at higher rates than Whites, male Native Hawaiian/Pacific Islanders between the ages of 25–44 report higher rates of death by suicide than White Americans [30].

2.6 Multiracial or mixed race

Multiracial/Mixed Race populations are unique because they are most likely to struggle with identity development and feelings of ostracization, which directly affects their mental health [32, 33]. Adolescents who identify as multiracial or mixed are at a higher risk of suicide, substance use, and depression as compared to adolescents who identify with being in a single race or ethnic category [33, 34]. Additionally, mixed-race adolescents are at a higher risk than White adolescents of having overall poor mental health and to have significantly fewer protective factors [34]. The main social determinants that multiracial or mixed-raced people experience that exacerbates mental health include familial discrimination, racial discrimination, and racial identity invalidation [35].

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3. Effects of treatment engagement

Risk factors known to contribute to the prevalence and vulnerability of mental illness within REM communities are vast, and entail coping with significant life events, while simultaneously managing systemic barriers that are unique to their race. Examples of life events experienced by the majority include bereavement, a lack of access due to finances or distance, and poverty, while examples of unique systemic barriers include having minimal or inaccurate knowledge about mental health care, cultural mistrust, cultural attitudes towards mental health care, stigma, and lack of proper assessment and care due to multicultural incompetence, and social determinants (e.g., racial or ethnic discrimination, implicit bias, racialized violence, etc.) [14, 23, 36]. Common cultural barriers are discussed in the next section. As there is diversity among REM, there is also diversity in the risk factors that make these groups vulnerable to mental illness.

3.1 Cultural mistrust

There are a variety of systemic barriers that REM minorities experience when seeking mental health treatment. A few common barriers are cultural mistrust, stigma, lack of access or knowledge of treatment, and financial difficulties [5, 37]. Cultural mistrust, also known as healthy cultural paranoia, refers to an inclination of distrust or skepticism that people of color have about White people when interacting within multiple contexts, such as education, healthcare, business, criminal justice system, etc [38]. The cultural mistrust that exists in communities of color stems from a history of racism, violence, and other social oppressions, which continue to inform US systems (e.g., medicine, education), industries (e.g., healthcare), and policies [38]. Even within the history of medical research, oppression was prevalent, such as the inhumane treatment conducted on REM minorities for the sake of medical advances. The US has a long history of marginalizing Black and Brown people for experimentation. In the 1840s, Dr. Marion Sims, “the father of gynecology” performed several surgeries on female slaves without anesthesia to better understand the female reproductive system [39].

Several historical studies revealed how the science and medical communities dissected and mutilated Black Americans and other ethnic minorities for decades under the guise of medical treatment and development. The Tuskegee Syphilis Experiment withheld antibiotics and without consent, which allowed the disease to run its course on groups of Black men serving as participants. During the 1970s, the University of Southern California-Los Angeles Medical Center sterilized Puerto Rican women by misinforming and forcing them into participation [39]. As a mechanism of scientific experimentation, REM developed a healthy skepticism about the true motive of White people in Western medicine and the intent of science, which continues to exist today [39]. As a result, REM attitudes toward seeking treatment for physical or mental health problems are informed by distrust, which in turn makes them reluctant to obtain help. As well, as racism and oppression continue to be embedded in US medical science, providers without cultural competence, humility, and sensitivity further marginalize REM through the improper assessment and treatment of REM. “Over 30% of Black people, 20% of Latinx people, and 23% of Indigenous people report avoiding medical care because of experiences of personal discrimination due to their race or ethnicity in health care settings” [40]. The fears of seeking help due to cultural insensitivity are transmitted across generations. Thus, cultural mistrust serves as a direct systemic barrier for REM’s decision-making about seeking treatment, which exacerbates mental illness in these communities.

3.2 Stigma

When exploring the multidimensional nature of mental health stigma within communities of color, it is essential to exercise sensitivity and to understand that communicating intimate, familial issues to a stranger can feel like one is crossing cultural boundaries. Mental health stigma refers to derogatory or demeaning attitudes one has about mental illness; it is described as a) personal stigma, b) self-stigma (e.g., internalized attitudes), or c) institutional stigma (e.g., reflected in systemic or mainstream society) [41]. Cognitive processes, stereotypes, affective processes, prejudices, and behavioral processes, or discrimination inform one’s experience of stigma as the “stigmatizer” or the “stigmatized” [42]. There are differences in how mental health stigma affects REM and their mental health [42]. Among some Asian Americans, stigma may include upholding the “save face” mentality by not seeking psychological treatment to protect their family’s reputation [43]. Stigma may derive from individuals in their own community given the constant flow of misinformation about mental illnesses [41]. In some REM communities, people who choose to seek help may become the object of ridicule in their communities, which can lead to even more reluctance or apprehension to seek treatment [42]. To avoid shame and denial, some Black or African Americans may abuse substances as a means to cope with mental illness instead of seeking help [44]. In order to address the stigma that exists in these communities, there must be increased awareness and easier access to education about mental illness and mental healthcare.

3.3 Lack of access

There is a complex relationship between the utilization of mental health treatment and poverty-stricken neighborhoods [21, 27]. The adverse social conditions in certain geographic locations contribute to the vulnerability or manifestation of some psychological disorders [45]. As REM are more likely to reside in impoverished neighborhoods, they are more likely to lack accessibility to the education or resources needed to access psychological treatment [45]. Many Native Americans, for example, live in rural or isolated areas that do not offer the needed services, and transportation can be a deterrent to seeking treatment if one does not have a car or needs to spend a long time traveling to receive services [43]. Black or African Americans living in rural areas may believe there are better resources available in larger, more urban cities and may think the resources provided in their rural communities are either of poor quality or nonexistent [46].

3.4 Financial barriers

Financial barriers play a considerable role in people’s reluctance to seek therapy. Some individuals are fearful they cannot afford mental health treatment and may never get help. While some REM lack the health insurance coverage necessary to see mental health professionals, others may have health insurance but may reside in a community where the majority of practitioners are self-pay only [47]. Due to a lower percentage of Latino/a with access to health insurance coverage, they are unable to financially afford mental health services [48]. As compared to their White counterparts, Black or African Americans and Latino/as earn lower incomes, receive less education, are least likely to have health insurance coverage, are more likely to be underinsured, and have a higher probability of being involved with the public- or social-service agencies [47]. And thus, each of these systemic barriers has an impact on the capacity to seek and obtain mental health services. These barriers need to be addressed on a systemic scale so that policy and funding can be allocated for the development of a mental health system that is inclusive and representative of all ethnic minorities.

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4. Effectiveness of evidence-based treatment

In the US, nationwide health disparities and systemic barriers impede REM access to quality mental health services [49, 50]. REM are less likely to seek and engage in mental health services as compared to their White counterparts [49, 50, 51]. Additionally, those who opt to engage in mental health services believe that evidence-based is culturally appropriate, or report dissatisfaction from treatment engagement [49, 51, 52]. Evidence-based practices (EBPs) are defined as the combination of empirical research, clinical expertise, and the lived experiences, values, and identities of participants [9, 11, 53, 54]. Evidence-based treatments (EBTs) refer directly to the clinical interventions, supported by scientific research, that are implemented to promote positive therapeutic outcomes [9, 49, 53, 54]. EBTs are often utilized to treat anxiety disorders, depression, posttraumatic stress, trauma, chronic pain, eating disorders, and other mental health conditions [52, 55, 56, 57, 58, 59, 60]. Examples of clinical interventions include Cognitive Behavioral Therapy (CBT), Narrative Exposure Therapy (NET), Eye Movement Desensitization and Reprocessing (EMDR), and Cognitive Processing Therapy (CPT) [52, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69].

4.1 Evidence-based treatments

CBT is an empirically supported therapeutic treatment that is guided by the basic principle that exposing, challenging, and reshaping distorted thoughts, modifying behavioral patterns, and managing affective processes can increase positive coping skills and improve mental health [70]. Research demonstrates the effectiveness of CBT in the treatment of a variety of mental health conditions, to name a few: anxiety, depression, stress, substance use disorders, and chronic pain management with people throughout their lifespan [56, 71].

NET is a short-term, trauma-focused, therapeutic treatment that was originally developed for those experiencing trauma due to exposure to disaster, war, and torture [63, 72]. A significant component of NET is the perception that trauma is not an isolated event but is interwoven into an overlapping network of various traumas that contribute to distorted sensory and cognitive information and can lead to the development of posttraumatic stress [63, 72, 73]. NET assists individuals in processing these traumas through creating a narrative that chronologically maps traumatic events across their lifetime, rather than focusing on a single traumatic event [63, 73]. NET is effective in the treatment of posttraumatic stress disorder (PTSD), anxiety, depression, insomnia, and other trauma-related disorders [72, 73, 74, 75].

EMDR is an empirically supported therapeutic intervention that was developed in the late 1980’s when researcher, Francine Shapiro, observed that engaging in saccadic eye movements, while recalling traumatic memories, significantly reduced the intensity of anxiety associated with these disturbing thoughts [65, 76]. EMDR is proven to be effective in mitigating the impact of traumatic stress, anxiety, and depression through aiding participants in processing dysfunctional memories and developing more adaptive cognitive processes [52, 66, 76, 77, 78].

CPT is an evidence-based cognitive therapy that is commonly utilized to treat PTSD [79]. CPT provides participants with psychoeducation about trauma, stress, and cognitive skill-building to aid in the identification of “stuck points” that form distorted thought processes that contribute to symptoms of posttraumatic stress [79, 80].

4.2 EBTs with REM populations

Despite widespread acceptance in the treatment of trauma and other mental health conditions, EBTs are often critiqued for a lack of cultural relevance [11, 81]. Historically, REM have been underrepresented in the scientific research that informs the efficacy of these interventions [49, 53, 54, 82, 83]. Researchers believe that this underrepresentation compromises the efficacy of these treatments among minority populations, and may negatively influence participant engagement, outcomes, and treatment satisfaction [49, 53]. Researchers investigate and address this disparity through the implementation of culturally competent programmatic modifications to traditional EBTs [52, 60, 79, 84, 85]. And thus, it is essential that practitioners be conscientious of cultural factors that inform REM perceptions of mental illness, the nature of their presenting concerns, and their desire or propensity to seek help; the EBTs that are utilized will not account for or address the nuances these individuals experience.

In one empirical study, researchers modified CBT interventions to be culturally inclusive for Mexican American women struggling with binge eating disorders. Findings suggested the eating habits of Latina women were significantly affected by both the cultural meaning of food and cultural beliefs surrounding help-seeking behaviors [60]. The women were less likely to be motivated by thinness ideals than their White counterparts and were more likely to engage in binge eating behaviors due to food signifying love, community, and other factors of their culture. In other words, the Latinas’ experiences were informed by cultural beliefs that implied they should be considerate of others before caring for themselves, which made them less likely to engage in treatment for their eating disorders [60]. Adaptations for the CBT intervention included guiding participants in navigating culturally specific social interactions about food, assisting participants in navigating culturally relevant healthy food options, and advocating for culturally competent service delivery.

Furthermore, it is necessary to implement cultural modifications to meet the unique needs of specific populations, such as refugee survivors [64]. Another common EBT, NET, is often used with diverse populations, such as refugees who experience trauma by exposure to war, torture, political unrest, anxiety, and depression [63, 64, 74, 75]. In another investigation of the cultural appropriateness of EBTs, NET was empirically examined and modified to address the specific needs of Cambodian survivors. The research adapted a NET intervention to meet the needs of Cambodian survivors of the Khmer Rouge genocide [86]. The adaptation included the implementation of traditional spiritual practices, such as chanting, protection rituals, and the presence of Buddhist monks to supplement the traditional NET intervention format [86]. The participants were responsive to this treatment approach.

4.3 Cultural appropriateness of EBTs

It is common for some investigators to examine the efficacy of traditional EBTs on specific minoritized populations. For example, one study attempted to examine the efficacy of a traditional EMDR intervention with Black or African American clients [52]. Several themes emerged that inform future adaptions to EMDR as an efficacious intervention for Black or African American clients. More specifically, the findings indicated the participants had insufficient psychoeducation on EMDR, which contributed to fear, uncertainty, and feelings of powerlessness regarding participation in the intervention. Additionally, the participants lacked trust and felt they were unable to identify with the White treatment providers who administered the intervention [52]. Combine these findings with Black or African Americans’ experience of systemic barriers; not only will they be less likely to seek treatment, but also their mental health conditions will deteriorate. An example of a study where researchers made cultural adjustments to an EMDR intervention to meet the needs of Syrian refugees includes implementing a translation of program materials into the local language, adjusting to a scheduled time (preferred evening schedules), and providing a discreet location for intervention services to decrease the possibility of stigmatization for receiving mental health services [55].

Spanish-speaking Latino populations face unique barriers when treated with EBTs. Shortages of Spanish-speaking clinicians, lack of access to bilingual program material, and limited protocol about culturally appropriate adaptations to EBTs are examples of unique barriers that Spanish-speaking Latino populations experience that can exacerbate their mental health or deter them from seeking help [85]. When seeking to culturally adapt a CPT intervention to meet the needs of Spanish-speaking Latinos managing PTSD, one study found that participants reported a lack of language accessibility of materials, difficulty understanding psychological terms, and poor integration of cultural values in program materials to be challenging [85]. Findings from a similar empirical study identified comparable barriers when adapting a CPT intervention for Native American women diagnosed with Human Immunodeficiency Virus (HIV), PTSD, and who were engaged in high-risk sexual activities [87]. These barriers included difficulty understanding scientific language presented in program materials as well as lack of spiritual and cultural relevance. Another CPT intervention was modified to address the needs of Kurdish trauma survivors living in Iraq [84]. Adaptations to the CPT manual and materials included the removal of American cultural idioms, reduction of psychological terms, translation of materials into Kurdish language, adjustment of language to create greater accessibility across literacy levels, and implementation of culturally appropriate case examples.

Today, researchers advocate for more culturally competent clinicians and propose cultural modifications to EBTs to help improve outcomes for REM who are participants in these interventions [52, 57]. As well, more REM need to be invited to participate in clinical trials when examining the efficacy of EBTs. Challenging clinicians to be creative in their clinical work, such as using clinical tools like the Multidimensional Model for Developing Cultural Competence (MMDCC) to guide practice can also improve psychological outcomes for REM clients [88]. The components of the MMDCC include cultural awareness, cultural knowledge, cultural knowledge of behavioral health, and cultural skill development and the components examine how these factors intersect at the individual, clinical, and organizational levels. Additionally, adaptations of intervention language are widely accepted as a culturally competent adjustment to EBPs [89]. There is presently no universal protocol for the culturally competent modification of EBTs [57, 89].

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5. Mindfulness-based stress reduction

MBSR was originally developed to reduce psychological and emotional stressors experienced by people with chronic health issues [12, 90]. MBSR has been administered to a wide range of populations in different settings, such as hospitals, schools, and prisons [90]. An advantage of MBSR is its format as a group training program that are led by either one or two trained instructors who facilitate group sessions [91, 92]. In order for MBSR to be most effective, instructors should have competency in teaching the program, embody qualities of mindfulness, commit to good practice, and be engaged in the learning process [90].

For participants, a potential benefit of MBSR is the shared experience of addressing various psychosocial stressors in a supportive group setting. Specifically, MBSR is administered as an 8 to 10-week training program intended to reduce stress through the systematic application of mindful-based practices [12, 91, 92]. Groups can range from 10 to 40 participants who meet weekly for a 2.5 hour MBSR training session. Activities for each session often include mindfulness meditation, mindful awareness, yoga, and mindfulness practice for stressful events [12, 92]. As a requirement of MBSR, participants are assigned a 45-minute homework task. These daily homework assignments include practicing different mindful-based exercises learned in each session. Mindfulness is developed through regular and repeated practice, which helps people readily access the techniques during stressful events [92].

5.1 Effectiveness of MBSR

The application of MBSR is an effective non-pharmacological method toward managing stress deriving from chronic physical illnesses (e.g., cancer, diabetes, hypertension, HIV) [93]. In fact, studies found that the practice of MBSR enhances coping skills while being used as an alternative medical treatment for clinical patients [92, 93]. For treatment of physical health conditions, reportedly MBSR decreases patient complaints of sensory pain, physical impairment, and medical symptoms. Furthermore, even non-clinical populations indicate improved quality of life after participating in MBSR [12, 92]. Overall, empirical findings suggest that MBSR can be utilized as a healthy coping strategy to manage a range of physical ailments.

In terms of mental health treatment, MBSR is found to be an effective approach in reducing symptoms related to anxiety disorders (e.g., generalized anxiety, social anxiety, panic attacks); more specifically, symptoms that relate to worrying and future-oriented cognitions [94, 95]. Furthermore, individuals with anxiety disorders report improvements in transdiagnostic symptoms (e.g., emotion dysregulation, avoidance, cognition) after completing a course of MBSR [94]. These participants indicated that MBSR was a beneficial activity to reduce their anxiety, helped them feel at ease, and gave them the confidence to do more activities. Based on these findings, MBSR is a clinical intervention that can be utilized to guide individuals toward change and acceptance of their anxiety [94].

Although, the clinical efficacy of MBSR extends beyond the treatment of various anxiety disorders and physical ailments. Among both clinical and non-clinical groups, MBSR has been found to be moderately effective at reducing depressive symptoms and psychological distress [12, 92, 96]. Moreover, MBSR is shown to decrease depressive symptoms and slightly improved cognitions among individuals with mild cognitive impairment. These results indicate that MBSR can be used as a supplemental treatment for mild to moderate depressive disorders [96].

Additionally, the effectiveness of MBSR as an alternative treatment for clinical ailments may be attributed to neurological change. In one study, neuroimaging data indicated increased connectivity in the visual and auditory networks of participants who completed an 8-week course of MBSR [97]. Likewise, the increased neurological connectivity was associated with improved attentional focus, sensory processing, and awareness of sensory experiences [97]. Similar neuroimaging studies found increased connectivity in the hippocampal region of participants after completing MBSR [98]. As a result, the findings suggested increased hippocampal connectivity from mindfulness may improve stress resilience and fear extinction (e.g., worry) [98]. And thus, MBSR as a clinical treatment promotes beneficial neurological growth and regeneration, which positively affects physical and mental health outcomes.

5.2 Effectiveness of MBSR for racial and ethnic minorities

The efficacy of MBSR as an EBT for physical and mental health conditions is well documented. However, there is a dearth of research that promotes mindfulness-based interventions as a treatment for REM populations. There are a few studies that demonstrate MBSR as a potential culturally appropriate treatment for a wide range of clinical ailments. For example, Native American, Latinx, and Black communities often uphold values that honor the mind-body and spiritual connection. Mindfulness-based techniques are inclusive of historical, social, and cultural perspectives or ideologies, which align with the needs of REM communities. And thus, the mindfulness-based interventions can promote communal coping (e.g., community or collectively) and healing (e.g., prayer, meditation, other spiritual rituals) [99].

In another example, MBSR can serve to reduce health disparities for Black or African American females experiencing the stress or traumatic stress deriving from sexism and racism [100]. In turn, MBSR can help Black women overcome harmful cultural or racialized stereotypes such as the Superwoman schema and the Strong Black woman script. A recent investigation found that prediabetic Black or African Americans notable decreases in diabetes risk (i.e., lower A1C) after completing an MBSR program [13]. These participants reported increases in spiritual well-being and reductions in perceived stress, BMI, and fat. These studies indicate that MBSR served as a culturally appropriate treatment for African Americans experiencing psychosocial stressors.

The benefits of mindfulness-based interventions (MBI) such as MBSR and mindfulness-based cognitive therapy (MBCT) have also been examined for REM and age demographics. A recent study found that culturally adapted mindfulness-based interventions for Latinx populations were correlated with improvements in depression, stress, and chronic illness [101]. Similarly, MBSR and MBCT were found to reduce depressive and anxiety symptoms among various Asian communities [102]. After participating in MBSR, low-income older African Americans reported decreased stress, depression, and anger and decreased blood pressure [103, 104]. Findings also indicated that young African Americans with HIV that completed MBSR experienced decreased hostility and improvements in social relationships, academic achievement, and physical health [105]. Thus, there is evidence that mindfulness-based interventions are culturally sensitive and inclusive, which aligns with the needs of REM coping with mental health conditions.

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6. Conclusions

REM are at a particularly high risk of experiencing mental health conditions. Social determinants of health, such as poverty, racialized violence, or discrimination exacerbate REM mental health and quality of life. REM are less likely than White people to seek and receive treatment. Furthermore, REM are more likely to experience systemic barriers, such as cultural mistrust, mental health stigma, lack of access, and lack of financial resources, further complicating their willingness and capacity to seek treatment. While EBTs are identified as empirically supportive to treatments for a range of mental health conditions, there is skepticism about their cultural appropriateness and relevance for REM populations. Clinicians must be culturally competent and use clinical tools (e.g., Multidimensional Model for Developing Cultural Competence) to assist in promoting cultural competence. Practitioners must be conscientious and knowledgeable about the pitfalls of EBTs when working with REM. Mindfulness-based techniques, such as MBSR, are culturally sensitive and inclusive of historical, social, and cultural ideologies that align with the needs of REM. MBSR has the potential to offer holistic coping given its effectiveness in promoting neurological, physical, and psychological healing.

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Acknowledgments

There are no acknowledgments to disclose for this work.

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Conflict of interest

There are no conflicts of interest pertaining to the authors to report or special circumstances for this work.

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Notes/thanks/other declarations

Thank you to all the authors who came together to get our message out. I would like to express my sincerest gratitude to the students who helped me.

References

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Written By

Tiffany Williams, Esther Lynch, Paigean Jones, Jeffery Bass and Rhea Harrison

Submitted: December 19th, 2021 Reviewed: February 24th, 2022 Published: April 29th, 2022