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INVITED PAPER
Cultural competency in the treatment of obsessive-
compulsive disorder: practitioner guidelines
Monnica T. Williams* , Traleena M. Rouleau, Joseph T. La Torre and Noor Sharif
University of Ottawa, School of Psychology, Ottawa, Ontario, Canada
*Corresponding author. Email: Monnica.Williams@uOttawa.ca
(Received 13 July 2020; revised 9 September 2020; accepted 14 September 2020)
Abstract
This article provides clinical guidelines for basic knowledge and skills essential for successful work with
clients who have obsessive-compulsive disorder (OCD) across ethnic, racial and religious differences.
We emphasise multiculturalist and anti-racist approachesandtheroleofcultureinshapingthe
presentation of OCD in clients. Several competencies are discussed to help clinicians differentiate between
behaviour that is consistent with group norms versus behaviour that is excessive and psychopathological
in nature. Symptom presentation, mental health literacy and explanatory models may differ across cultural
groups. The article also highlights the possibility of violating client beliefs and values during cognitive
behavioural therapy (CBT), and subsequently offers strategies to mitigate such problems, such as consulting
community members, clergy, religious scholars and other authoritative sources. Finally, there is a discussion
of how clinicians can help clients from diverse populations overcome a variety of obstacles and challenges
faced in the therapeutic context, including stigma and cultural mistrust.
Key learning aims
(1) To gain knowledge needed for working with clients with OCD across race, ethnicity and culture.
(2) To understand how race, ethnicity and culture affect the assessment and treatment of OCD.
(3) To increase awareness of critical skills needed to implement CBT effectively for OCD in
ethnoracially diverse clients.
(4) To acknowledge potential barriers experienced by minoritized clients and assist in creating
accessible spaces for services.
Keywords: cultural competency; diversity; ethnic minority; exposure and ritual prevention therapy; mental health disparities;
obsessive-compulsive disorder; treatment outcomes
Introduction
This article is intended to provide guidelines surrounding basic competencies and skills that are
essential for successful work with clients across ethnic, racial and cultural differences. It has been
known for some time that minoritized groups have been under-represented as both mental
health professionals and clients receive specialized care for obsessive-compulsive disorder
(OCD) (e.g. Williams et al., 2015a). Minoritized groups include Black, Indigenous and People of
Colour (BIPOC) in the USA and Canada, and Black, Asian and Minority Ethnic (BAME)
groups in the UK. In this article, these ethnoracially minoritized groups will be referred to as
people of colour (POC). The seeds for this article were planted a few years ago when the
International OCD Foundation brought together a diverse group of experts for the purpose of
improving awareness, access and specialized clinical care for POC with OCD. This article was
© British Association for Behavioural and Cognitive Psychotherapies 2020.
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inspired by that initiative, developed to give voice to cultural knowledge specific to OCD, and to
make important competencies and skills more accessible to the larger body of cognitive
behavioural practitioners.
OCD is a severe, disabling disorder, characterized by the presence of obsessions and
compulsions, where obsessions are unwanted and distressing thoughts, images or impulses,
and compulsions are repetitive behaviours intended to reduce distress associated with
obsessions. A person with OCD may suffer from a variety of symptoms; however, primary
dimensions of OCD symptoms include contamination and cleaning, symmetry and ordering
or arranging, doubts about harm and checking, and unacceptable thoughts and mental rituals
(Williams et al., 2013c).
People with OCD have heightened rates of other mental health disorders such as major depression,
eating disorders, substance use disorders and anxiety-related disorders, as well as poor physical health
(Himle et al., 2008; Witthauer et al., 2014). As such, they experience a lower quality of life across
important functional domains such as leisure, relationships, work and educational activities.
OCD is found across race, ethnic group and nationality, and it is estimated to afflict
approximately one in sixty individuals over their lifetimes (Williams et al., 2017b).
Western perspective
In directing ourselves towards a multiculturalist and anti-racist orientation, it is important to
appreciate that these guidelines emanate from a primarily Western perspective. This means
that the theoretical framework, explanatory models and research procedures undertaken to
gain the knowledge provided herein follow from this frame of reference. It should be noted
that other cultures may have different explanatory models with regard to mental health, and
specifically OCD, and as such may not completely accept a cognitive behavioural therapy
(CBT) conceptualization of how OCD is maintained or how to alleviate it.
It is essential that clinicians recognize that clients may be members of communities that are
marginalized and stigmatized due to race, ethnicity, culture and/or religion. This means they
experience discrimination, reduced opportunities and limited access to a society’s resources,
including medical care. This may pose additional difficulties that need to be addressed in
treatment. Such clients may need more time to develop trust and rapport with a therapist,
and may have additional fears about being stereotyped due to their unwanted OCD thoughts
and behaviours (Williams et al., 2017c).
Ethnic identity and acculturation
Ethnic identity is a multi-faceted construct that describes how people develop and maintain a
sense of belonging to their ethnic heritage. Important factors influencing a person’s ethnic
identity include whether they identify as a member of an ethnic group, their sentiments
toward their ethnic group, their self-perception of group membership, their knowledge and
commitment to the group, and their ethnic-related behaviours and practices. Research shows
that for minoritized individuals, a strong positive ethnic identity can provide resilience in the
face of discrimination.
Another relevant and related construct is acculturation, traditionally defined as the extent to which
people from different cultures adopt the values and participate in the traditional activities of dominant
culture. Recent re-conceptualizations of the acculturation process utilize a multi-dimensional
perspective, where minoritized individuals must reconcile discrepancies in their identities
(ethnic versus national identity), value system (individualism versus collectivism), language
proficiency, cultural attitudes and knowledge, and cultural practices (Chapman et al., 2018).
Acculturative statuses include strongly adhering to the mainstream culture and devaluing one’s
original heritage (assimilation), strongly adhering to the original heritage and devaluing the
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dominant culture (separation), and exhibiting little interest in adhering to either cultural stream
(marginalization) (see Yoon et al., 2013). Biculturalism, or the ability of individuals to effectively
integrate elements of two cultural streams, is thought to be one of the most protective
acculturation statuses against negative health outcomes, despite high levels of minority stress
(Chapman et al., 2018).
Aside from having knowledge of ethnic identity and acculturation, mental health professionals
must also understand how these constructs interact to influence treatment-seeking and outcomes.
In one popular model (Carter et al., 1996), minoritized people who maintain a strong ethnic
identity and are highly assimilated in the dominant culture will endorse traditional beliefs of
mainstream society (e.g. individualism) and exhibit symptom presentations consistent with
Western diagnostic nomenclature. Notably, these individuals may believe psychological
treatment is effective while maintaining some mistrust of societal systems in the dominant
culture as a result of significant cultural experiences (e.g. racism and discrimination).
Similarly, those low in ethnic identity yet highly assimilated will exhibit a traditional symptom
presentation, but be more willing to seek, persist through, and benefit from traditional
treatment practices. In contrast, individuals who do not identify with the dominant culture
(separation or marginalization acculturation status) may display unique symptom
presentations and utilize culturally specific explanations for their symptoms, thereby resulting
in a greater likelihood for misdiagnosis. Furthermore, these individuals are less likely to seek
treatment due to mistrust or limited knowledge of mental health care (Chapman et al., 2018).
Traditional healing practices
Many individuals utilize traditional healers to improve mental health, and it is not uncommon for
individuals with OCD to enlist the support of spiritual and religious leaders. If the therapist
believes that religion is causing or worsening the OCD, the therapist may try to control or
suppress the person’s beliefs to facilitate treatment. However, this may undermine trust and
empathy, leading to conflict and drop-out. Therefore, whenever possible, therapists must work
respectfully within the confines of the client’s religious rules and traditions, which will
ultimately facilitate treatment adherence. Indeed, the importance of culture is discussed in
many psychological associations’ethics codes, including the American Psychological
Association’s(2017)Ethical Principles of Psychologists and Code of Conduct, the Canadian
Psychological Association’s(2017)Canadian Code of Ethics for Psychologists, and the British
Psychological Society’s(2018)Code of Ethics and Conduct. These codes underscore the
requirement for psychologists to seek additional training, consultation and supervision when
practising outside their scope of competence. The avoidance of harm is also a central
principle and such harm may include disrespecting and violating a client’s cultural and
religious values. Clinicians must thus consider and integrate clients’values into the provision
of OCD treatment.
Other than mainstream religions, there are also alternative healing practices that are connected
to mental health, as many groups have introduced their approaches to health and wellbeing into
Western culture through immigration and globalization. Often referred to as complementary and
alternative medicine (CAM), these approaches may include Ayurveda, yoga, herbal medicine,
acupuncture, Voodoo, astrology, Santeria, and new age therapies (Moodley and Sutherland,
2010), as well as traditional Chinese medicine (Liu, 1981), meditation (Neki, 1973) and/or
shamanism (Metzner, 1998). Clinicians should be prepared to discuss the role of traditional
medicine and CAM in the client’s treatment. It is important to show respect for these systems
and acknowledge indigenous, cultural and traditional healing practices, many of which are
time-honoured methods that have been used to alleviate both physical and psychological
problems for generations. When a conflict is experienced between a therapist and a traditional
healer, it is advisable to collaborate with the healer rather than to force the client to make a
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choice between the two, as clients will generally choose their traditional healer over a mental
health clinician (Pouchly, 2012).
Purpose of this article
The following competencies and skills are grounded in literature examining various ethnoracial
groups’experiences of OCD or mental health, more generally. They have been selected through
the authors’own empirical investigation, consultation with colleagues, and clinical experiences.
While the findings may not apply to every client of colour, they may serve as a source of
consideration for clinicians. This article assumes some basic skills in the ability to have
conversations with clients about race, ethnicity and culture, but therapists who feel uncertain
in their ability to comfortably navigate this can reference a number of good books and articles
on this topic, tailored to the delivery of CBT (e.g. Beck, 2019; Williams, 2020; see also the
‘Further reading’section at the end of this article). We emphasize that the underlying
principles of reflection, respect, consultation and integration serve as the cornerstone of
culturally competent and client-centred treatment. In addition, it is ideal for clinicians to
demonstrate cultural humility through approaching other cultures with openness and respect,
while prioritizing continual personal and professional growth (Hook et al., 2013).
Speciality knowledge
There are a number of areas where specialized knowledge is necessary to understand OCD across
race, ethnicity and culture. The following sections describe the importance of knowledge in the
areas of bias and culture, stigma, differences in symptom expression, the impact of discrimination,
measurement issues, and treatment efficacy.
Awareness of personal biases and knowledge gaps
Some qualities that are integral to therapists effectively delivering treatment to minoritized clients
include awareness of their own biases, awareness of gaps in knowledge about diverse clients they
might serve, and awareness of how biases and gaps could negatively influence interactions with
clients. Without being cognizant of personal biases and knowledge gaps, clinicians are more likely
to overlook important cultural issues or fail to discuss them appropriately. It is not uncommon for
therapists to ignore or change the subject when unfamiliar cultural issues arise or to proceed with
interventions that are unacceptable to a client’s cultural values (Chapman et al., 2018; Williams,
2020). Similarly, therapists may unknowingly convey insensitivity or disrespect through their
words and actions, which may include statements about a person or their group in alignment
with inaccurate or hurtful stereotypes (e.g. Williams and Halstead, 2019). Worse yet,
therapists who have not worked to address their own prejudices may lash out at clients when
their own biases are questioned.
Biases and gaps in cultural knowledge may also result in a lack of engagement in treatment and
premature drop-out by clients. This underscores the need for effective and ongoing training in
culturally sensitive care. When working with people from unfamiliar cultural groups,
therapists should educate themselves on the client’s culture. This may include consulting with
community members or clergy, or seeking supervision with a knowledgeable clinician
(Huppert et al., 2007; Williams et al., 2017c). Furthermore, adopting approaches to build
rapport and improve the therapeutic relationship can be important, and one recommended
behaviourally based interpersonal approach is functional analytic psychotherapy (FAP; Miller
et al., 2015). The successful use of FAP has been described in detail as a useful supplement to
exposure and ritual prevention (Ex/RP) in a case study of a Latino American with OCD
(Wetterneck et al., 2012).
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Stigma and mental health literacy
Individuals from communities of colour experience greater mental health stigma, which reduces
the likelihood of accessing mental healthcare (Turner et al., 2016; Williams et al., 2012b; Williams
et al., 2017c). Stigma can be related to cultural concerns of bringing the family shame, being
perceived as ‘crazy’and being hospitalized, confirming false racial stereotypes, accessing
mental healthcare that is viewed negatively in the cultural community, and beliefs that having
a mental illness or accessing mental health care are signs of weakness (Turner et al., 2016).
Compared with White parents of children with OCD, a study conducted in the UK showed
that minoritized parents were more likely to fear stigma and discrimination from within their
families and cultural groups (Kolvenbach et al., 2018). Shame and denial of mental health
symptoms also emerged as salient barriers for patients of colour. In addition, the importance
of religion in many communities may discourage clients from disclosing religious obsessions
(Beşiroğlu et al., 2010; Glazier et al., 2015b). As OCD is associated with significant shame and
stigma (Glazier et al., 2015b), additional cultural and societal stigma can compound a
sufferer’s fears.
Mental health literacy references the ability to recognize specific disorders, know how to
acquire mental health information and treatment, understand risk factors and causes, and
adopt attitudes that facilitate recognition of disorders and appropriate help-seeking. Due to
reduced representation, education and exposure to mental health care, individuals from
minoritized communities may not recognize the development, presentation or treatment
options for many mental health conditions (Turner et al., 2016; Williams et al., 2017c),
including OCD which is not often recognized by laypersons (Chong et al., 2016), therapists
(Glazier et al., 2013), physicians (Glazier et al., 2015a) and clergy (Jones et al., 2019). New
immigrants may also be unaware of available resources or fear deportation if their mental
health or documentation status is in question (Turner et al., 2016). Recognition of a mental
health problem as a legitimate concern may also be precluded by symptom somatization, as
well as cultural mistrust of mental health professionals (Williams et al., 2017c).
Fernández de la Cruz and colleagues (2016) presented ethnoracially diverse parents with
hypothetical vignettes in which their child was depicted as having OCD symptoms. White
British parents perceived more symptoms, interference and treatment effectiveness associated
with OCD than Indian parents. In addition, White parents also perceived greater treatment
effectiveness than Black Caribbean parents and more symptoms and interference than Black
African parents. Collectively, White participants demonstrated the most knowledge about
OCD. These findings highlight a need to consider the mental health literacy of individual
clients and to integrate psychoeducation on OCD in outreach, assessment and treatment
approaches.
Cultural variations in OCD symptom expression
Culture can significantly impact the expression of OCD symptomatology, and as such, understanding
cultural differences in symptom expression is integral to effective assessment and treatment. Current
understanding of OCD phenomenology suggests a multi-dimensional structure in which symptoms
centre on contamination, responsibility for harm, symmetry, and/or unacceptable thoughts
(Abramowitz et al., 2010; Williams et al., 2013c). Empirical consideration of cultural differences in
the expression of these dimensions is emerging. Cultural influences may inform the presentation
and under- and over-endorsement of each dimension. Williams et al.(2017d) demonstrated that
expected gender differences in endorsement of contamination and unacceptable thoughts
dimensions were not present in a sample of African American participants. The authors theorized
that greater cultural variability in gender roles in African American culture may account for the
inability to find greater contamination symptoms in women and greater unacceptable thoughts
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symptoms in men (Orbuch and Eyster, 1997). Furthermore, as considerations of morality are culture-
bound, moral and religious concerns embedded in the unacceptable thoughts dimension may differ
dependinguponanindividual’sculturalbeliefs.
Culture can also influence the rates of endorsement of certain symptoms. Research on OCD in
African Americans has shown that African Americans experience contamination symptoms at twice
the rate of European Americans (Wheaton et al., 2013; Williams et al., 2012c; Williams and
Turkheimer, 2007). One study found that African Americans with OCD were first identified in
New York dermatology clinics due to skin irritation from prolonged washing and exposure to
cleaning materials. Fifteen per cent of the participants in the sample were diagnosed with OCD,
which is significantly higher than would be expected in a non-psychiatric sample (Friedman
et al., 1993). Another study conducted at an Egyptian hospital demonstrated that 7.4% of
dermatology out-patients presented with OCD symptoms (Motawa et al., 2020). At the same
time, most dermatology out-patients with OCD endorsed contamination symptoms. These
findings illustrate that POC may be seeking other types of medical care for their concerns.
Some studies also demonstrate elevated contamination concerns in Latinx samples (Williams
et al., 2005). Moreover, it has been found in a non-clinical Mexican sample that the most frequent
obsessions were related to contamination (Nicolini et al., 1997). Sexual, symmetry, danger and
aggressive obsessions were the next most prevalent obsessions in the sample. Furthermore, a
study in Rio de Janeiro examined the content of reported obsessions in Brazilians, with the
most common theme focused on aggression, contrary to conventional contamination centred
on symptom expression (Fontenelle et al., 2007; Matsunaga et al., 2008). Katz and colleagues
(2020) did not find greater contamination concerns in any non-White group, but they did
find higher rates of magical/superstitious thinking among POC. An over-representation of
certain symptom subtypes within ethnoracial groups necessitates a consideration of how
stigma and oppression may influence the content of OCD symptoms.
Stigma and oppression embedded in obsessional concerns
Clinicians should understand stigma and oppression in marginalized ethnic groups –including
sociocultural hierarchies, minority experience, racialization, White privilege, caste systems, etc. –
and how these may be embedded in obsessional concerns. Oppressive and traumatic experiences
can influence the nature of individuals’obsessions. For example, African Americans are twice as
likely to report animal-related concerns compared with European Americans (Williams and
Ching, 2017). This may hold historical cultural relevance because animal attacks (e.g. dogs)
were historically used to hunt for slaves and attack civil rights protestors (Williams et al., 2012c).
Previous experiences and negative ethnoracial stereotypes can also affect the phenomenology of
OCD for minoritized individuals. Stereotype threat refers to the negative affect and arousal evoked
in situations where a group member’s behaviour can confirm the negative stereotype about their
character in a specific domain (Ben-Zeev et al., 2005; Steele et al., 2002). The endorsement of
contamination symptoms in African Americans may be an example of this. Higher rates of
obsessions and compulsions related to themes of cleanliness may hold cultural relevance for
African Americans, as they have historically experienced segregation due to European American
fears of contamination through close contact or sharing objects (Devine, 1989).
When stereotypes and prejudices towards specific groups are salient, affected groups prioritize
self-representation strategies to decrease apparent confirmation of the stereotypes and prejudice.
Research has found that endorsement of contamination avoidance and aversion by African
Americans was greater when stereotype cues were made salient (Olatunji et al., 2014).
These findings suggest that amplified views about the importance of cleanliness among African
Americans may function to compensate for negative stereotypes about African Americans.
Williams et al.(2017e) also found that African Americans who report everyday racial
discrimination are more likely to experience contamination obsessions, as well as unacceptable
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thoughts obsessions. African Americans may also be hesitant to disclose sexual or aggressive
obsessions for fear of validating false racial stereotypes of being sexually deviant or violent
(Williams et al., 2017c). Increased efforts at suppressing such thoughts may in turn lead to
greater pre-occupation and obsession (Wegner et al., 1987).
There is some evidence to support the idea that minoritized individuals have greater fears of
not saying the right thing or being misunderstood (Fernández de la Cruz et al., 2015; Williams
et al., 2012c). Such trends may reflect participants’desire to compensate for previous negative
racial stereotypes of appearing unintelligent (Fernández de la Cruz et al., 2015; Williams et al.,
2012c), and may manifest as compulsive repeating of certain words. It is important to note
that clinicians’own stigmatizing attitudes towards minoritized individuals may also lead to
diagnoses that confirm pathological stereotypes, including severe mental illness like psychosis,
instead of OCD (Chapman et al., 2018). For example, in a case study by Ninan and Shelton
(1993), one African American client expressed the delusional belief that blasphemous thoughts
were being inserted into his head by Satan. Due to the belief that such thoughts were not
generated from his own mind but were rather being inserted into him, he was misdiagnosed
with psychosis. Upon closer examination, however, it was revealed that the client also had
obsessions with the number seven, as well as compulsions around bathroom rituals and
negating his blasphemous thoughts, and so an OCD diagnosis was more appropriate.
The connection between discrimination and OCD
Major and everyday discrimination (e.g. microaggressions) negatively affects physical and mental
health and is also linked to higher risk and severity of psychiatric disorders in racialized
communities (Berger and Sarnyai, 2015). As previously discussed, discriminatory stereotyping
experienced by communities of colour appears to influence OCD symptomatology, as well as
the severity of OCD symptoms. Williams and colleagues (2017e) demonstrated that African
Americans who reported greater experiences of everyday racial discrimination had a greater
number of obsessions and compulsions, and a higher risk of meeting diagnostic criteria for OCD.
Having several marginalized identities can compound the effects of discrimination on OCD
phenomenology. Intersectionality refers to belonging to two or more communities that have
been historically marginalized (Wadsworth et al., 2020). Race, ethnicity, gender, sexual
orientation and ableism constitute some examples of identities that may be societally
privileged or marginalized according to group membership. Wadsworth et al.(2020)
demonstrated that holding more marginalized identities increased OCD symptom severity in
the contamination, harm and symmetry dimensions at baseline and discharge for OCD
patients. Furthermore, having more marginalized identities was related to increased obsessive
beliefs about responsibility/threat over-estimation and perfectionism/certainty at both time
points. The authors posited that this relationship could be attributed to marginalization’s
effect on anxiety symptoms or the inability of assessment tools to measure culturally
normative beliefs and values. In addition, the adoption of cleanliness, symmetry, completeness
and perfectionism tendencies may be adaptive for overcoming difficulties associated with
being marginalized. Experiencing individual and systemic discrimination may also heighten
fears around perceived harm and concerns about responsibility and threat.
Encountering discrimination when seeking mental health treatment may be a concern for POC.
Seeking treatment may evoke feelings of shame, fear or stigma for having mental health issues at
all, and reveal a lack of trust towards the mental health system and therapists (Williams et al.,
2017d). Parents also report concerns of systematic discrimination when seeking help for their
children of colour (Kolvenbach et al., 2018). In comparison with White British parents, Black
African parents were more likely to agree that they would dislike judgement or discrimination
of their cultural or ethnic background from a doctor (Fernández de la Cruz et al., 2016).
Therapists treating OCD symptoms in POC should discuss how their clients are appraising
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and managing experiences of racial discrimination. Additionally, although extremely challenging
for clients, clients should be encouraged to persist in their help-seeking efforts, despite the barriers
to treatment posed by concerns about discriminatory experiences.
Because the typical client seeking treatment for OCD is White, clinicians may have stereotypes
about what sort of problems POC are most likely to have, and that may bias their diagnoses
accordingly. Indeed, White individuals with OCD are more likely to receive counselling, Ex/RP
or medication in relation to OCD symptoms in comparison with minoritized individuals (Katz
et al., 2020). Co-morbidity in OCD is the rule rather than the exception, with high rates of
co-occurring depressive, anxiety, traumatic and substance use disorders (Himle et al., 2008).
Data examining co-morbidity specifically in racialized communities demonstrates that a
staggering majority of African Americans with OCD experience another co-morbid
psychological disorder (Himle et al., 2008; Williams et al., 2017a). Mental health professionals
commonly misdiagnose OCD (Glazier et al., 2013), and may misdiagnose minoritized clients at
a higher rate (e.g. Ninan and Shelton, 1993) due to differing cultural representations of
symptoms and their unconscious confirmation of pathological racial stereotypes (Chapman
et al., 2018). Clinicians’limited knowledge of OCD symptoms and inadvertent confirmation of
their own stigmatizing stereotypes of minoritized clients may thus reduce the focus on OCD
symptoms. This can cause clinicians to focus on another problem at the expense of the OCD,
which may in fact be driving the co-morbid conditions. For example, one Black research
participant we assessed shared that he had requested help for his OCD, but his mental health
provider wanted to focus on his depression and other issues instead. The clinician kept putting
the OCD on the back burner, saying ‘We’ll tackle that later’, and as a result, the patient never
got treatment for the OCD. Furthermore, the intense stigma associated with OCD and African
Americans’reported concerns of discrimination and uncertainty of whether to access help for
OCD concerns may reduce the likelihood of clients advocating for focusing on OCD concerns
in-session (Williams et al., 2012b).
Validated OCD measures may be inadequate for diverse populations
Clinicians should understand that validated OCD measures may be inadequate for minoritized
populations. For example, previous findings suggest that African Americans, Latinx Americans
and Asian Americans all endorse higher rates of contamination concerns than European
Americans (Wheaton et al., 2013). It was also found that perfectionism and difficulty
tolerating uncertainty were more predictive of contamination concerns for Asian Americans
than for African Americans, Latinx Americans and European Americans (Wheaton et al.,
2013). Furthermore, maladaptive perfectionistic symptoms among East Asians specifically may
be linked to traditional cultural values (Markus and Kitayama, 1991; Yoon and Lau, 2008),
and are further reinforced and reified by the high expectations their parents, teachers and
peers may have of them (Schneider and Lee, 1990).
OCD symptoms are varied, and as a result of this tremendous variance, it comes as no surprise
that instruments used to measure OCD symptom presentation in non-White samples may not
capture the heterogeneity of diverse experiences. Several OCD instruments have not been
normed on diverse populations, including both self-report measures and structured interviews.
Some instruments shown to be problematic include the Maudsley Obsessional Compulsive
Inventory (MOCI; Hodgson and Rachman, 1977), the Padua Inventory (Sanavio, 1988) and
the OCD section of the Structured Clinical Interview for the Diagnostic and Statistical Manual
of Mental Disorders-IV Axis I Disorders (SCID-I; Spitzer et al., 1992).
Awareness of this issue emerged in a study conducted by Thomas et al.(2000), where it was
found that Black undergraduate students consistently produced higher scores on the MOCI in
comparison with White participants. This was also demonstrated with the Padua Inventory,
where White respondents scored significantly lower on contamination items than Black
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participants (Williams et al., 2005). Williams et al.(2013b) found that African Americans scored
significantly higher on nearly every subscale of the Obsessive-Compulsive Inventory Revised
(OCI-R; Foa et al., 2002) in comparison with a primarily European American OCD group,
demonstrating the need to adjust the measure’s cut-off score for African Americans to 36
rather than 21 as proposed in the original validation study. This higher cut-off was used in a
study of Black South African women post-partum, and a cut-off of 36 flagged 39% of
participants, versus 81% with the lower cut-off (Malemela and Mashegoane, 2019), which
indicates cross-cultural variability in subjective reporting of symptom severity. In addition, the
Dimensional Obsessive-Compulsive Scale (DOCS) has evidenced excellent reliability and
promise amongst several ethnoracial groups in the USA, although validation studies are
needed with clinical samples (Wheaton et al., 2013; Williams et al., 2012a; Williams et al., 2015b).
In terms of structured interviews, the Structured Clinical Interview for the DSM-IV Axis I
Disorders (SCID-I) OCD module is limited for being largely influenced by the administrator’s
clinical experience, and therefore often produces inconsistent results, especially with African
American clients (Chasson et al., 2017). For example, it was found that the SCID-I OCD
module was more likely to miss less severe clinical levels of OCD in African Americans,
particularly when interviewees did not endorse the presence of obsessional thoughts and/or
compulsive rituals due to lacking insight and/or awareness. On the other hand, in a study
conducted by Williams et al.(2013e), the Yale–Brown Obsessive Compulsive Scale (Y-BOCS;
Goodman et al., 1989a; Goodman et al., 1989b) was found to be valid for measuring OCD
symptom severity in African Americans. Therefore, a measure’s utility in effectively assessing
OCD symptoms within diverse populations may relate to its capacity to both account for
ethnic and racial differences, as well as accurately capture symptomatic severity even when the
client misreports or under-estimates symptoms. The Diagnostic Interview for Anxiety, Mood
and OCD and Related Neuropsychiatric Disorders (DIAMOND; Tolin et al., 2018) is a newer
interview that has not yet been examined in diverse populations.
CBT treatment approaches may not be as effective for people of colour
CBT and its subset of Ex/RP represent treatments of choice for OCD. However, clinicians should
recognize that CBT itself is rooted in European values and that randomized clinical trials of OCD
treatment effectiveness have mostly involved White participants (Hays, 2009; Williams et al.,
2010). The development and assessment of contemporary OCD approaches using mostly
White people necessitates an investigation of the treatment’s effectiveness on POC. In the UK,
Fernández de la Cruz et al.(2015) compared White and non-White children and adolescents’
OCD phenomenology and treatment response to CBT. Both groups largely demonstrated
phenomenological similarities, except for the existence of three marginally significant findings.
A trend existed for ethnic minority clients to endorse fears of not saying the right thing and
for White clients to endorse engagement in superstitious games and rituals with others.
These patterns suggest that CBT treatment targets for non-White youth may differ from those
for White youth. Importantly, Fernández de la Cruz et al.(2015) demonstrated that White
and non-White youth responded equally well to CBT.
Another study conducted by Williams et al.(2015a) explored treatment response to CBT in
White and non-White children, adolescents and adult clients at a large multi-site specialty
treatment facility between 1999 and 2012. As expected, clients were predominantly White but
the clinic evidenced a significant growing trend to admit more ethnoracially diverse clients in
recent years. In comparison with White participants, minoritized clients had significantly
longer treatment durations but did not demonstrate any differences in symptom severity or
change scores. The authors hypothesized that differences in treatment duration may relate to
cultural differences between clients of colour and the predominantly White clinicians.
Promoting clinician and institutional cultural competency can help to ensure that culture is
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integrated and prioritized in treatment. Such integration facilitates effective mental health care
that is truly responsive to clients’diverse needs and preferences.
Culturally informed adaptations to CBT can enhance treatment efficacy for minoritized
individuals (e.g. Williams et al., 2014). As previously mentioned, a comprehensive and
continually developing cultural understanding and assessment of diverse client groups is
essential. Williams et al.(2014) suggest the use of additional measures that assess ethnic
identity (e.g. the Multigroup Ethnic Identity Measure; Phinney, 1992) to provide information
about clients’cultural connections that may be employed in the course of treatment. In
addition, measures that assess experiences of racism (e.g. the General Ethnic Discrimination
Scale; Landrine et al., 2006) can also provide useful information about clients’previous
experiences of discrimination, which may affect OCD symptomology and in-session dynamics.
Measures like the Brief Religious Coping Scale (Pargament et al., 1998) and Valued Living
Questionnaire (Wilson et al., 2010) may also identify client strengths and values that can be
used in treatment. Social support networks may be especially important for minoritized clients
so clinicians should explore the involvement of important others in treatment (Williams
et al., 2014).
Specialized skills
There exist a number of areas where specialized skills may be necessary to successfully treat OCD
across race, ethnicity, culture and religion. Skills are a step beyond knowledge as they require effort
and training to put into practice. The following sections describe the importance of skills in the
areas of outreach practices, cultural respect, flexibility, working with family, differentiation of
OCD symptoms from cultural practices, use of culturally specific explanatory models,
therapeutic use of the client’s worldview and spiritual traditions, and devising acceptable
exposures.
Culturally informed outreach practices
Clinicians can adopt several principles and approaches to increase accessibility of services for
POC. Clinicians must actively consider their own biases towards minoritized clients to prevent
under-serving individuals from these communities (Kugelmass, 2016; Williams et al., 2012b).
As cultural mistrust of mental health care is also a barrier to seeking services (Kolvenbach
et al., 2018; Williams et al., 2017c), clinicians should endeavour to practise transparency when
communicating goals and expectations for treatment (Williams et al., 2012b). Use of the term
‘counselling’instead of ‘therapy’may reduce concerns and stigma (Thompson et al., 2004). In
addition, offering free initial sessions and telephone consultation may help to familiarize
clients with services and reduce therapy fears (Williams et al., 2012b). Having ethnically
matched and culturally competent staff can also be very helpful for outreach (Turner et al., 2016).
In addition, treatment cost may be a significant concern for POC from low-income
communities (Turner et al., 2016; Williams et al., 2012b; Williams and Jahn, 2017). This
concern is especially pronounced for those who are not eligible for publicly or privately
insured mental health care. Advertising treatment options that range in price (e.g. use of
practicum students, stepped care, adoption of a sliding scale) may increase treatment
participation and engagement (Williams et al., 2012b). Reduced treatment cost can also
support financial losses that are associated with pursuing treatment, like lost wages, childcare
and transportation costs (Williams et al., 2012b). Such considerations are especially necessary
as there may be fewer OCD treatment options in non-White communities (e.g. Williams and
Jahn, 2017).
Awareness of OCD and available treatment options can be improved by maintaining regular
contact with community leaders and hosting free community events on mental health (Turner
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et al., 2016; Williams et al., 2012b). Clinicians may also provide referral information to primary
care professionals to ensure accessibility of services (Williams et al., 2013d). Referral notices can
integrate culturally relevant language and describe symptoms in somatic terms for groups that
tend to somatize their mental health experiences (Turner et al., 2016). Treatment should also
be advertised as incorporating holistic and alternative approaches that are valued by clients
from diverse backgrounds. Acknowledging cultural beliefs and the impact of racial trauma
may also increase client comfort and engagement. These strategies can also be employed when
promoting services to children, adolescents and families. The need for culturally competent
outreach for adolescents, children and families is evident, as a UK-based study illustrated that
Black African parents perceived greater barriers to seeking help for potential OCD symptoms
experienced by their child than White British, Indian and Black Caribbean parents (Fernández
de la Cruz et al., 2016). These parents were the least likely to seek help for a child’s OCD
symptoms.
Integrating clients’perspectives and preferences into treatment
Consideration and integration of minoritized clients’worldviews and experiences is an essential
component of cultural competence (Hays, 2009). Conventional therapeutic approaches’
Westernized and present-focused protocols may not always align with diverse clients’lived
experiences (Hays, 2009). Individualized conceptualizations of clients’problems may discount
social oppression (Sue and Sue, 2016), collectivistic approaches, family hierarchies and spirituality.
Instead of exclusively promoting rapport within session, clinicians can also focus on overt
demonstrations of respect for clients, which may be more valued in many cultures (Hays,
2009). As repeated questioning is perceived as disrespectful in several cultures, providing
clients with space and autonomy throughout assessments may promote respect for their
preferences (Hays, 2006). Carefully integrating self-disclosure (when appropriate) within small
talk may also promote respect for clients who value a warm personal approach (Organista,
2006). Respect can also be demonstrated through understanding clients’reluctance to answer
certain questions that reflect poorly on the client’s culture or family (Paradis et al., 2006).
Similarly, collectively integrating culturally related strengths and self-care activities may
promote respect and increase treatment engagement (Hays, 2009).
In addition, clinicians can modify their treatment medium or approach to integrate clients’
worldviews and experiences. For example, Organista (2006) demonstrated that framing group
therapy as an educational experience reduced stigma in Latinx clients. Paradis et al.(2006)
highlighted that framing OCD treatment as individual therapy may respect Orthodox Jewish
clients’treatment preferences and reduce shame. In addition, Black clients may prefer the use
of an Afrocentric approach in which positivity, perseverance, faith and family are integrated
(Williams et al., 2014). Some minoritized clients may also value a more directive approach,
which runs counter to conventional therapeutic norms (Sue and Sue, 2016). Clinicians should
also be aware that some minoritized clients may value non-verbal communication or engage
in greater concealment as an adaptive measure for protection (Sue and Sue, 2016).
It is also imperative to validate clients’experiences of oppression and refrain from offering
alternative hypotheses, even though certain therapeutic approaches encourage exploration of
differing explanations, as this can invalidate a client’s culture (Hays, 2009). Instead, clinicians
can encourage clients to evaluate the helpfulness of certain thoughts or beliefs instead of
questioning their validity. Williams et al.(2014) also detail how clinicians can provide
psychoeducation about how racism may contribute to symptomatology (e.g. Williams et al.,
2017e). Clients may further benefit from hearing examples of how treatment has benefited
other minoritized clients with OCD (Williams et al., 2014). As clients may be resistant to
disclose their symptoms due to cultural mistrust, previous experiences of discrimination and
stigma, extra sessions to build rapport may be beneficial.
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As each cultural group is diverse, cultural adaptations to Ex/RP will be significantly different
for each client. Clinicians can benefit from exploring previous empirical work and consulting with
colleagues on cultural adaptations to existing Ex/RP protocols for specific groups. The
investigation by Aslam et al.(2015) of a successful brief culturally adapted CBT for OCD in a
sample of Pakistani clients elucidates the need for more research evaluating culturally adapted
Ex/RP for OCD and provides some useful examples (for a broad overview of cultural
adaptations for anxiety and depressive disorders, see Hinton and Patel, 2017). As minoritized
individuals may consider therapy as only one means for change, the integration of culturally
relevant activities or healing techniques to supplement treatment progress will probably prove
beneficial (Williams et al., 2014).
Creating a comfortable environment for treatment
Clinicians should be sensitive to practical aspects when working with minoritized clients to help
create a comfortable environment for treatment and reduce potential barriers to care. Clinicians
should also be flexible surrounding time, scheduling and location.
It is important to note that concerns over treatment cost may vary internationally, based on
availability of services and coverage offered for psychological services (including the UK’s
coverage of treatment through the NHS). However, if treatment is inaccessible, inconvenient
or affects opportunities for employment, clients can be universally affected. First, cultures vary
in their orientation towards the concept of time. As such, strict start and end times for some
clients may not be appreciated or understood. Integration of a flexible approach to
appointment start and end times may increase client comfort and respect.
African Americans cite their occupation, other commitments and transportation as affecting
their availability for treatment (Williams et al., 2012b). These concerns are heavily endorsed by
individuals who are younger and who have reduced financial resources. Similarly, parents of
colour in the UK reported time, money and location inconvenience as barriers to seeking
mental health support (Kolvenbach et al., 2018). Clinicians can work to reduce barriers
associated with childcare or caring for relatives. Financial constraints and stigma can also be
reduced by selecting comfortable community settings with accessible and affordable childcare
(Turner et al., 2016; Williams et al., 2013a). Offering appointment times that consider clients’
working schedules and other commitments may also abate financial and logistical concerns.
Working with families
OCD affects family relationships, and African Americans with OCD report impairments in their
ability to meet their family obligations due to their symptoms (Himle et al., 2008). Family
members may also experience frustration and burn-out associated with their loved one’s OCD
symptoms. A study conducted in Egypt demonstrated that reported family burden between
individuals with OCD and individuals with schizophrenia was comparable (Negm et al., 2014).
Another study conducted at an Indian hospital illustrated that family members of patients with
schizophrenia reported greater overall burden, financial burden and disruption of routine family
activities than family members of individuals with OCD (Gururaj et al., 2008). However, no
statistically significant differences existed between both populations’disruption of family leisure
and family interaction, and effect on physical and mental health of others. Thus, the family
burden for OCD is generally similar to that experienced with other severely impairing mental
health conditions and is present in several aspects of family functioning. As such, OCD afflicts
not just individuals, but their families as well.
In most cultures, family relationships are heavily valued and thus central to the treatment
process (Mehta, 1990). Elders are highly respected and honoured by all Asian cultures, and in
many cultural groups, parents or grandparents will have the last word on whether treatment
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is permitted. Due to the low participation of POC in OCD research, representative information on
the efficacy of family-based treatment is limited (Wetterneck et al., 2012). In India, Mehta (1990)
demonstrated that a family-based intervention consisting of directed family member supervision,
responsibility and support of recovery resulted in significantly greater improvement of OCD
symptoms. The importance of social support from family members for communities of colour
suggests that group or family-based therapy may be promising options for OCD treatment
(Wetterneck et al., 2012). The existence of extended family structures for such clients also
communicates that clinicians’integration and championing of family support in
psychotherapy would prove beneficial (Ruggles, 1994; Williams et al., 2017c). To increase
treatment participation, clinicians should involve family in consultation and psychoeducation
as gaining family support and trust will help the client feel more motivated to stay in
treatment and may contribute to an increased prioritization of treatment (Williams et al.,
2012b). Families can also be included in the treatment process, through encouragement to
complete homework and direct help with exposures if the client is agreeable.
It is also important to note that OCD symptomatology can be affected by various aspects of
family life, including family accommodation of OCD behaviours and expressed emotion
(consisting of loud communication, criticism, arguments, intrusiveness and demeaning
behaviours) (Himle et al., 2017; Vaughn and Leff, 1976). While both dimensions have been
associated with poorer treatment outcome or increased symptomatology (De Berardis et al.,
2008 Lebowitz et al., 2012), few studies examining family behaviours have incorporated
information on ethnicity. With a nationally representative sample of African Americans and
Caribbean Blacks, Himle et al.(2017) found that individuals with OCD reported significantly
higher negative family interactions than those without OCD. Positive family and friend
relationships did not attenuate the likelihood of developing OCD. Thus, negative family
interactions remain a more potent contributor to OCD symptomatology than positive sources
of support. Clinicians must assess the existence of negative family communication patterns
and provide family with psychoeducation on OCD and its relationship with negative family
interactions to improve treatment outcomes.
Interpersonal difficulties and associated enmeshment from OCD difficulties may be
particularly harmful in collectivistic cultures and necessitate additional consideration by
clinicians (Williams et al., 2017c). Within collectivistic cultures, creating individual identities
that are separated from the family may not be desirable, and so clinicians should aim to
communicate treatment as supporting both the family and individual client. Because of the
importance and reliance on family support, clinicians should thoroughly assess for family
accommodation behaviours that may be misperceived as supporting the client. In addition,
client concerns of shaming or dishonouring family members must be considered and respected.
Distinguishing OCD symptoms from cultural and religious practices
Clinicians should both recognize that clients’religions do not cause OCD and accept clients’
legitimate religious practices. A client’s religious values should be respected and integrated
into treatment when possible, as often the OCD gets in the way of carrying out proper
religious duties (i.e. prayer, attendance at services, normal rituals) rather than improving
religious life (Himle et al., 2012; Huppert et al., 2007). The clinician should demonstrate that
adherence to excessive, OCD-driven religious behaviour is debilitating and impairing over
time (Huppert et al., 2007), and differentiate it from normative cultural and religious
practices. For example, in one study examining religious OCD symptoms among young
Muslim women from Saudi Arabia, it was found that the most prevalent symptoms were
centred around the five daily prayers and their preceding ablution rituals (Al-Solaim and
Loewenthal, 2011). All interviewees in the study found their OCD symptoms related to
religious life as most distressing, interfering, time-consuming and physically exhausting when
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compared with obsessional behaviour in other domains of life such as schoolwork. In addition to
being distressing, interviewees reported that their religious OCD also resulted in significant
impairment, with one participant stating that she repeated prayers so many times she had to
miss school on several occasions and another acknowledging that she began taking too long
to complete ablution practices.
Scrupulosity OCD exists in religious communities across all traditions, although recent
findings indicate that scrupulous presentations may vary between religious affiliations
(Buchholz et al., 2019). For example, among Jewish and Christian groups, Christians engage
in greater moral thought–action fusion, an element of OCD (Siev et al., 2010). They argued
that moral thought–action fusion was culturally normative for Christians and only predicted
OCD symptoms in Jewish populations. This finding is consistent with original research that
demonstrates that non-Christian groups report reduced scrupulous symptoms (Abramowitz
et al., 2002), which could be attributed to the influence of Christianity on current scrupulosity
measures (Summers and Sinnott-Armstrong, 2019).
Understanding culturally predicated explanatory models for OCD symptoms
Individuals from minoritized communities may use culture-specific models to inform their
understanding of their symptoms, and as such, clinicians must be able to understand the
client’s culturally predicated explanatory model for OCD symptoms. In the UK, Fernández de
la Cruz et al.(2016) demonstrated that participants’perceived causes for their child’s
hypothetical OCD symptoms differed based on ethnoracial identity. For example, White
British and Black Caribbean parents most commonly attributed personality, emotional
problems, trauma and family/parenting problems as causing OCD symptoms. However,
Indian parents also believed in the influence of their child’s friends instead of a potential
trauma and Black African parents also selected physical causes instead of family or parenting
problems. Black African parents were also less likely to endorse biopsychosocial causes for
OCD symptoms than White British parents. Non-White individuals were also more likely to
report that they would seek help for OCD symptoms from a religious leader.
An international survey study found notable East–West differences in explanatory models for
OCD (Yang et al., 2018). Compared with respondents in the USA and Western Europe, people in
East Asia had more negative views about someone with OCD. East Asian participants were more
likely to blame the person, consider the symptoms to be part of the person’s personality, and
recommend the sufferer to not seek help from others. Those from East Asian countries were
also more likely to recommend alternative therapies like acupuncture and herbal medicines.
Those from Western countries had a more favourable view of causes and psychosocial
interventions for treating the disorder.
In another study, approximately one-third of OCD out-patients from an Indian hospital reported
seeking support from faith healers or exorcists and almost half associated their OCD symptoms with
supernatural causes, including sorcery, ghosts, spirit intrusion, divine wrath, planetary influences,
evil spirits and wrongdoings in a past life (Grover et al., 2014). Moreover, 34% of clients attributed
their symptoms to more than one supernatural cause. Clients who initially consulted faith healers
and traditional healers for their symptoms were more likely to have beliefs in spirit intrusion, sorcery
and/or witchcraft. These clients were also more likely to attribute their symptoms to various
supernatural causes. In addition, clients who attributed their mental illness to past bad deeds in
a previous life had significantly longer durations of illness. Thus, clinicians must consider the
prevalence of culturally predicated models and their effects on the treatment process and outcomes.
For clients with strong religious affiliations, religious OCD symptoms may be internally and
externally stigmatized and attributed to previous inadequate developmental experiences and
excessive religiosity instead of medical and psychological explanations (Pirutinsky et al., 2009).
Such attributions may amplify shame and ostracization in such individuals. As the study of
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Grover et al.(2014) highlighted that about half of out-patients reported magico-religious beliefs
within their community, it is imperative that clinicians understand the influence of cultural
beliefs held by both clients and community members to ensure accessible and representative
care. Indeed, parents of colour cite differing cultural beliefs about mental illness as a barrier
to seeking treatment for their children (Kolvenbach et al., 2018). Awareness and integration
of cultural models within psychological models is thus a necessary component of clinical
cultural competence.
For some ethnic groups such as African Americans, framing OCD as an inherited, biological
disorder rather than a ‘mental illness’is more acceptable and less stigmatizing. African Americans
are socialized to be mentally strong, and may fear that OCD is a sign of mental weakness, whereas
having a treatable medical condition may be seen as more acceptable. On the other hand, among
East Asian groups, mental disorders are highly stigmatized due in part to their potential to be
inherited, which can make it hard to find marriage partners for people from families where
anyone has a serious mental disorder (Lauber and Rössler, 2007). As a result, it is advisable
for clinicians to frame OCD as learned habits that can be resolved through education and training.
Making treatment compatible with the client’s worldview
Conceptualizations of psychological well-being may vary cross-culturally (Yip, 2005). That being
said, while OCD symptoms may be group or culture specific (Williams et al., 2017b), they are
always distressing or impairing. Thus, clinicians must be able to translate clinical information
into a framework that is compatible with the client’s worldview for understanding and
treating OCD, while simultaneously being able to demonstrate that OCD symptoms are
psychopathological, and not due to individual or group differences. As a result, normative
behaviour in the community with which the client identifies can and should be used as a
reference point to distinguish between acceptable risk and OCD behaviour (Huppert et al.,
2007). For example, it may be appropriate for clinicians to ask questions such as, ‘Do your
friends also engage in this behaviour as intensely or frequently as you do?’(Huppert et al., 2007).
Similarly, it may also be useful for clinicians to consult community members in order to learn
what is considered normative within a client’s specific group/tradition (Huppert et al., 2007), as
well as to learn how to best translate and convey clinical information to clients in a manner that
corresponds to their worldview. Avoiding religious content in the therapeutic conversation is
unnecessary and often counterproductive (Leins and Williams, 2018). Within the Christian
community, there has existed antagonism between one camp of therapists espousing Biblical
counselling and the other championing a more ‘secular’form of psychotherapy, which has led
to even stronger opinions about whether it is advisable to highlight religious principles in the
therapeutic context (Leins and Williams, 2018).
While religion is not an aetiological factor in scrupulosity OCD (Huppert et al., 2007), notable
differences in symptomatic presentation across cultural and religious groups do exist, possibly due
to different conceptualizations of God or the Divine (Leins and Williams, 2018), or cosmology
more generally. For example, some religions such as the Abrahamic traditions, which
characterize God as sometimes punitive, may lay the groundwork for instilling an obsessional
fear of sinning or being condemned by God (Williams et al., 2017b). Meanwhile, other non-
theistic religions such as Buddhism may give rise to different fears such as the fear of
attaining a bad rebirth (Lam et al., 2010). Other fears may include fears that are not attached
to a specific religion, but rather attend to more supernatural concerns such as spirit
possession, demonic possession, or receiving a hex such as the evil eye (Spiro, 2005).
Clinicians must acknowledge these origins, effectively differentiate between cultural group
differences and psychopathology, and integrate beliefs and values when translating clinical
information to the client during treatment.
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Working with traditional healing and healers
Help-seeking behaviours may be culture specific and vary from group to group, with some clients
preferring the integration of spiritual, traditional and folk healers in their treatment. For example,
among Muslim populations, seeking out advice on how to deal with OCD symptoms from Imams
prior to mental health professionals is not uncommon (Al-Solaim and Loewenthal, 2011).
Clinicians should appreciate these modalities and collaborate with them as necessary.
Consulting a variety of experts on religion including clergy members, traditional healers and
religious scholars can prove useful in facilitating religious psychoeducation (Arip et al., 2018),
as well as in determining the boundaries of exposures for clients with OCD (Huppert et al.,
2007). One example of religious leaders’support is Islamic jurists’alleviation of OCD
symptoms through demonstrating that the Qur’an does not support ideas of thought–action
fusion or thoughts as consequential (Keshavarzi et al., 2018).
Clinicians can support their clients’spiritual beliefs through doing more than just acknowledging
them. Clinicians must also be willing to integrate religious and cultural values into the therapeutic
process. For scrupulous Christians, this means working with the Bible in order to facilitate a more
personal approach to treatment, as well as to validate any commitments to biblically oriented
therapeutic goals the client might have (Leins and Williams, 2018). In the Islamic context, this
translates to working with the Qur’an and the Hadith (Arip et al., 2018; Keshavarzi et al., 2018).
Integrating a discussion around clients’spiritual beliefs into the therapy process for individuals
with OCD has been shown to be extremely effective. For example, treating Christians with
scrupulous themes of OCD with Ex/RP that centralizes the compatibility of the intervention’s
tenets with Biblical scripture may be more effective than Ex/RP detached from culturally or
religiously sensitive narratives (Leins and Williams, 2018).
Collaboration with traditional and religious healers could encompass consulting healers
through national forums, establishing working alliances as joint mental health professionals,
consulting confidentially on the client’s case with the client’s consent, and inviting healers to
deliver training to clinicians to enhance cultural competence (Pouchly, 2012). Drawing from
interviews conducted with traditional healers in Uganda, Ovuga et al.(1999) outlined two
potential organizational systems for collaboration between traditional healers and clinicians:
(1) a sequential approach, in which clinicians and traditional healers could make referrals to
each other and (2) a simultaneous approach, in which healers and clinicians could operate
within the same service and receive joint training. The sequential approach may work best
within the context of the UK’s NHS and potential resource restrictions, but the simultaneous
approach warrants further consideration and study (Pouchly, 2012).
It is also important to note that both clients who are and are not religiously scrupulous may
endorse traditional approaches to healing, such as yoga, Ayurveda, astrology, Voodoo, Santeria,
Qi-gong and Sahaja, (Moodley and Sutherland, 2010), as well as traditional Chinese medicine
(Liu, 1981), meditation (Neki, 1973), and/or shamanism (Metzner, 1998). Clients may also
identify with traditions that have a long history of sacralizing entheogenic plants such as the
Santo Daime tradition of Brazil (Blainey, 2015). Examining spiritual beliefs and practices in
psychotherapy may provide the clinician with a greater understanding of clients as
represented through cultural metaphors, symbols and archetypes (Moodley and
Sutherland, 2010).
Devising exposures that do not violate religious or core cultural beliefs
Developing cultural sensitivity is particularly important when devising effective exposures that do
not violate a client’s religious tradition or core cultural beliefs. This is especially salient for certain
ethnoracial groups who report religious concerns as barriers to OCD treatment (Fernández de la
Cruz et al., 2016). In order to conceptualize what is and is not culturally permissible during Ex/RP,
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it may be useful for clinicians to consult a relevant clergy member or religious leader (Huppert et al.,
2007). This is recommended because exposures do not usually require individuals to bring about
negative consequences directly, but are rather designed to habituate the individual to ultimately
allow for tolerating risk, ambiguity and uncertainty surrounding an event. They also note that
while in vivo exposures can be effective, it is neither necessary nor appropriate to ask the client
to commit an actual sin (see also Williams and Wetterneck, 2019).
Imaginal exposures do not usually result in the client committing sin, and may also expose the
client to therapeutic scenarios that cannot be experienced in vivo such as going to Hell. Other forms
of culturally sensitive exposure techniques include integrated exposure and prevention therapy,
which seeks to incorporate a variety of religious elements in the form of religious
psychoeducation (Arip et al., 2018). This psychoeducation consists of teaching healthy
techniques to glorify God, listening to clergy members and scholars speak about scrupulous
behaviour, and regularly reviewing homework and assignments on scripture and holy texts
(Arip et al., 2018). Similarly, Aouchekian et al.(2017) showed that religious CBT is an effective
approach for treating religious OCD in a group of Muslim women. Sessions integrated the
clients’religious beliefs while directly targeting distorted cognitive beliefs which helped to
significantly reduce OCD symptoms, with gains persisting after 6 months.
Discussion
Summary
The current work highlights the importance of reflection, respect, consultation and integration of
different worldviews, models of mental illness, symptom expressions, experiences of oppression,
and values in the assessment and treatment of OCD. Clinicians must acknowledge and counteract
personal biases through introspection and consultation if they are to become culturally competent.
It is also integral that clinicians recognize many clients’experiences of compounded stigma from
both having OCD and being part of a racialized community that experiences oppression and
mistrust of the mental health system, as oppression, stereotype threat and stereotype
compensation have the potential to contribute to obsessional content and associated compulsions.
Standardized OCD assessment measures do not examine these factors adequately and are often
not validated on diverse populations. As such, they may be inadequate for assessing diverse
populations and may have the propensity to either over- or under-diagnose OCD symptoms
(Chasson et al., 2017; Thomas et al., 2000; Williams et al., 2005; Williams and Turkheimer,
2007). Clinicians should therefore use culturally validated measures like the OCI-R and
YBOCS, and when this is not possible, should consider the accuracy of test results and
communicate such findings with caution.
As discussed throughout, diverse clients may utilize many different avenues to find help for
their OCD. Common examples of alternate help-seeking behaviours among various cultural
groups can be summarized as follows (Turner et al., 2016; Williams et al., 2017b):
•Alternative healing methods (e.g. herbal medicine, acupuncture)
•Family and community advice and support
•Religious and spiritual sources of support
•Traditional or folk healers, clergy
•Engagement through primary care
•Use of emergency room services
Of course, we should not forget that many racialized people do seek help from professional
therapists and counsellors (e.g. Katz et al., 2020), and may still not find help for their OCD
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due to a shortage of mental health professions trained to treat OCD, which is likely to be even
more so in communities of colour.
One way treatment providers can increase client comfort and engagement is through
community consultations, accessible psychoeducation, transparent dialogue, and involvement
of diverse and culturally competent staff. In recruitment notices and exchanges with diverse
communities, mistrust and fear surrounding engagement in research and treatment should be
acknowledged. Offering treatment at flexible times, situating treatment at accessible locations,
and creating welcoming spaces for family and close others in-session and in treatment waiting
rooms can also offset many barriers. The importance of family to a client should be respected
and may be demonstrated through involving family in consultation and psychoeducation
about OCD, as well as providing information about the harms of family accommodation.
Family can also be an integral component of treatment when desired.
Clinicians should be open to adapting conventional therapeutic approaches and integrating
treatment approaches, which are cognizant of the client’s values. Differentiating experiences of
OCD from normative cultural and religious experiences may involve consultation with
community leaders and religious/spiritual healers, education on cultural experiences, peer
consultation with multicultural clinicians, and consideration of the distressing and impairing
nature of the behaviour. Such collaboration ensures that exposures do not violate religious,
spiritual or cultural norms. We also advise clinicians to respect and integrate clients’models
of attribution for their OCD symptoms and the importance of collaborative support with
religious and traditional healers.
Limitations
Some findings presented in the work above are based on the larger mental health literature as there
is a dearth of research specifically examining the relationship of OCD and culture. We also
acknowledge that relevant research conducted in other cultures that is not available in English
is not represented here. In addition, much of the discussed research and literature was
conducted in North America and Europe. Thus, researchers’understanding of OCD
symptoms and treatment may be influenced by contemporary Western conceptualizations of
mental illness.
The findings may also not be applicable to individuals with OCD from other countries. As it
may be difficult to assess all cultural groups in individual studies, some of the findings may be
limited to individuals of only one specific community. Lastly, the cross-sectional nature of
much of the discussed research limits the potential to make causal claims about diverse
individuals’experiences of OCD. It is important to note that individuals within cultural
groups experience idiosyncratic differences that may be distinct from their culture. Clinicians
should recognize that these findings and recommendations will not apply for every member of
a particular group. Clinicians should thus incorporate discretion and consultation, as well as
collaboration with clients to create conceptualizations and treatment approaches that reflect
the client’s individual preferences and experiences.
Future directions and research
Despite considerable progress over the last decade to better conceptualize OCD and OCD
treatment more broadly, more research is needed to understand symptom differences, cultural
attitudes and treatment approaches in non-White and non-Western populations. While
research has begun to explore common cultural variations of OCD in diverse populations, we
argue that researchers should expand these investigations and replicate previous results.
Expanding beyond religious OCD symptoms to explore how other aspects of culture influence
obsessional content is also of empirical and clinical interest. The impacts of acculturation and
18 Monnica T. Williams et al.
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generational status on OCD phenomenology, help-seeking behaviours and treatment response is
also considerably unexplored. In addition, researchers could further investigate how experiences
of microaggressions, oppression and racial trauma contribute to OCD symptoms and treatment.
Exploration of cultural manifestations of OCD within children and adolescents is also lacking
(e.g. Williams and Jahn, 2017).
Specific attention to the effectiveness of OCD treatment for POC is necessary to ensure that
existing protocols are reflective and representative of the entire population. Empirical
investigation of cultural adaptations to traditional Ex/RP protocols would prove beneficial in
understanding OCD and its treatment. Other sources of investigation could include the formal
integration of community leaders, healers and clergy, as well as complementary and
alternative medicine into treatment. Research could also investigate which culturally
responsive outreach practices are most effective within different ethnoracial communities.
Finally, prioritizing the selection of nationally representative samples (like that derived from
the National Survey of American Life or the National Latino and Asian American Study;
Jackson et al., 2004; Takeuchi et al., 2012) may also ensure generalizability of research on
OCD phenomenology and treatment.
Conclusion
There is ample evidence from both the larger mental health literature and the OCD literature
specifically that the competencies described herein are important for conceptualizing cultural
issues and treatment outcomes within communities of colour. We argue that clinicians should
consider and accordingly counteract any personal, organizational and therapeutic biases and
norms that do not integrate clients’diverse experiences. Furthermore, collaboration with other
professionals such as community and religious leaders, is necessary to produce culturally
competent assessments and treatment approaches that respect clients’worldviews and values.
Therefore, clinicians should be willing to adapt treatment, accommodate barriers and engage
in open, transparent dialogue with themselves, colleagues, community members and clients to
support the diversity of those in their care.
Acknowledgements. None.
Financial support. This research was undertaken, in part, thanks to funding from the Canada Research Chairs Program.
Conflicts of interest. The authors have no conflicts of interest to report.
Ethical statement. The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the
BABCP and BPS.
Key practice points
(1) Diagnosing and treating OCD can be complicated due to the wide variety of symptom presentations associated
with the disorder.
(2) Adding differences due to race, ethnicity, culture and religion can make working with this challenging disorder
even more complex.
(3) Therapists should understand that symptoms may present differently in various ethnoracial groups, due to
differences in ethnicity, culture, religion or race.
(4) CBT approaches may need to be adapted to account for different worldviews, religious beliefs and family
considerations.
(5) Therapists should consult with others as needed, including traditional healers, members of the client’s
community, and culturally competent mental health experts for guidance.
The Cognitive Behaviour Therapist 19
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Further reading
Hays, P. A. (2009). Integrating evidence-based practice, cognitive–behavior therapy, and multicultural therapy: ten steps for
culturally competent practice. Professional Psychology: Research and Practice,40, 354–360.
Rathod, S., Phiri, P., & Naeem, F. (2019). An evidence-based framework to culturally adapt cognitive behaviour therapy.
The Cognitive Behaviour Therapist,12, E10. doi: 10.1017/S1754470X18000247
Turner, E. A., Cheng, H. L., Llamas, J. D., Tran, A. G., Hill, K. X., Fretts, J. M., & Mercado, A. (2016). Factors impacting
the current trends in the use of outpatient psychiatric treatment among diverse ethnic groups. Current Psychiatry Reviews,
12, 199–220. https://doi.org/10.2174/1573400512666160216234524
Williams, M. T., Rosen, D. C., & Kanter, J. W. (2019). Eliminating Race-Based Mental Health Disparities: Promoting Equity
and Culturally Responsive Care Across Settings. New Harbinger Books. ISBN: 978-1-68403-196-2
Williams, M. T., Sawyer, B., Ellsworth, M., Singh, R., & Tellawi, G. (2017). Obsessive-compulsive and related disorders in
ethnoracial minorities: attitudes, stigma, and barriers to treatment. In J. Abramowitz, D. McKay, & E. Storch (eds),
The Wiley Handbook of Obsessive-Compulsive Disorders (pp. 847–872). Wiley.
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
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Cite this article: Williams MT, Rouleau TM, La Torre JT, and Sharif N. Cultural competency in the treatment of obsessive-
compulsive disorder: practitioner guidelines. The Cognitive Behaviour Therapist.https://doi.org/10.1017/S1754470X20000501
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