Cultural Humility in Digital Mental Health

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The ability to provide therapeutic services online has drastically changed the therapy landscape and the demand for digital solutions has continued to grow rapidly in the context of the COVID-19 pandemic. Research has shown that 55 percent of patients prefer to use digital tools instead of traditional in-person therapy, and that 25 percent prefer completely self-guided options. Given the significant shortage of providers across the globe, there is a need to find sustainable solutions to increasing mental health access at scale – and digital mental health solutions have found a way to meet that need.

Mental health apps are one avenue of scaling access to care and decreasing health disparities – but in practice, they sometimes perpetuate disparities. While there are a number of factors that contribute to digital health inequalities, a significant factor is the design of the apps themselves. Technology is not bias-free and racial biases in healthcare technology have led to everything from Black patients being scheduled for worse appointment times to greater errors in heart rate monitoring software for patients with darker skin colors.

To truly unlock the potential of mental health apps for increasing access to mental health resources, we need to approach the building of apps with cultural humility. Cultural humility is a concept described by Drs. Tervalon and Murray-Garcia, characterized by “a lifelong commitment to self-evaluation and critique, to redressing power imbalances in the physician-patient dynamic and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations.” The concept acknowledges that complete understanding of another person’s cultural experience is not possible, and instead promotes a stance of appreciating and respecting the cultural experience of others. It recognizes power imbalances and the existence of implicit biases while promoting respectful partnerships and accountability.

While this may initially not sound like a concept that lends itself to app development, the same could be said of the therapeutic alliance – and yet research has shown that it is not only possible for people to form meaningful therapeutic relationships with apps, but that those relationships predict clinical outcomes. Building on this, clients who view their therapists as having greater cultural humility have been found to have improved therapeutic alliance and better clinical outcomes.

To promote cultural humility, digital mental health solutions should use the following approaches:

1. Build apps in partnership with diverse experts and community members.

It’s critical to involve people from a variety of backgrounds, experiences, and viewpoints to ensure the products are effective for all. Rather than thinking of this technology as helping or “fixing” a particular marginalized community’s issues, members of that community can and should be equal collaborators and partners in creating solutions that are built and dispatched to serve their needs. Additionally, content should be created by experts with diverse backgrounds and areas of expertise in working with the populations that are served by the app.

2. Incorporate self-reflection and critique by collecting real-world evidence and feedback.
It can be tempting to assume digital mental health apps are addressing the needs of their core population from anecdotal feedback and controlled research studies alone, but without real-world evidence and robust internal and external feedback processes, it’s impossible to understand how to meaningfully address the challenges of those using the app. It is critical to continually question our own biases – to identify in what ways our own cultural experiences may be leading to microaggressions or discrimination within the app. A recent study in JMIR Mental Health advises that the design and development of digital mental health solutions be an iterative process, where each step of app development and assessment offers relevant inflection points for feedback and self-critique.

3. Don’t make assumptions.
It is a best practice of cultural humility to focus on self-identification. To do that, it’s important to create options within the app for people to indicate how they want to be referred to, their pronouns, their cultural identity, and their goals. Ask directly about previous mental health experiences, challenges, or goals through a process where users can enter their responses. Providing individualized care via digital mental health tools is a key part of following cultural humility and creating quality care.

4. Make suggestions for modifications to exercises to promote cultural relevance.
To the point of creating individualized care experiences through digital mental health tools, suggesting modifications to address cultural context will provide greater relevance and respect for individual experiences. This can be done by giving a variety of examples for exercises to adapt them for different cultural norms, and by specifically addressing the impact of racism on users' experiences.

5. Increase access to digital mental health resources.
Finally, increasing access to digital mental health resources in and of itself is engaging in cultural humility. Cultural humility focuses on addressing historical power imbalances and paternalistic relationships. Given that these factors have led to large disparities in access to mental health care, increasing access to quality mental health resources for historically underserved groups is representative of approaching these injustices through cultural humility.

Committing to cultural humility broadly, and in mental health app development specifically, can lay a foundation for building meaningful relationships that can have a positive impact on mental health care for all.