TABLE 5.

Providers’ perceived challenges, concerns, and unmet needs concerning early intervention in psychosis (EIP) programs

Category	Quotation
EIP programs or models can be too one-size-fits-all	Example 1: “I have seen a lack of knowledge and a one-size-fits-all approach leading to the service not being suitable for some people and their families.” Example 2: “Seeing psychosis through a mainstream lens I believe leads to misdiagnosis—overdiagnosis in some cases, underdiagnosis in others. And to treatment discontinuation. Better, clearer guidelines and training are needed for a truly culturally responsive early psychosis program.”
Underlying ethnocentrism in EIP models and practice	“Most of the [privileged models] are individualized approaches that are permeated by White, Western (male) worldviews, such as CBT [cognitive-behavioral therapy] and the medical model. Moreover, as these assumptions are taken for granted, they are not adequately critiqued. It is therefore difficult to work from the perspective of the individual client/family and attend to their cultural perspectives and needs when the wider system is not supporting such practice.”
Socioeconomic needs are decentered	“The model of the program does not prioritize needs related to socioeconomic disadvantage, and this means that in practical ways these needs are not adequately addressed and also that in more abstract ways these needs and experiences are disconnected from how problems are conceptualized and approached by staff. The primary focus [on therapy] at times translates into needs related to socioeconomic disadvantage being decentered and not being seen as key foci of treatment or recovery.”
Providers can be ethnocentric	“We still have a long way to go before clinicians in early intervention services understand cultural humility and sensitivity. The common belief that psychosis arises from a universal illness process prevents providers from seeing culture as meaningful, and cultural beliefs and experiences are still often misrecognized as ‘symptoms.’ Providers are also often unaware of (or even judgmental of) indigenous explanatory models and healing practices.”
Biomedical clinical frameworks are overemphasized	“There is an overemphasis on biological explanations for symptoms to [the] exclusion of a [broader] range of explanations.”
Lack of and need for team diversity	Example 1: “Having staff and peer and caregiver support workers from a variety of cultural backgrounds would help.” Example 2: “I think the best way to address cultural differences is to engage staff and clients from diverse cultural backgrounds when designing or improving early psychosis services.”
Lack of and need for deeper engagement with clients’ values, experiences, and priorities	Example 1: “Lack of knowledge and understanding of different religions (specifically Islam and Sikh) have proven to be a challenge within our clinic. It has resulted in assumptions being made that were untrue or hindered the progress of therapy, as specific recommendations or exercises were in direct contrast with a client’s religious values. I think the only way to best address cultural differences is to continue to steep ourselves in the experiences of others. Asking our clients questions about their experiences of their culture and religion is the only way to ensure we are understanding the ways in which these differences impact their lives. A continued open dialogue about remaining genuinely interested in understanding another person’s experience may help to keep clinicians aware of their own biases and need for education.” Example 2: “[I]t does seem that the standardized treatment formats (such as early intervention manuals) could be expanded to better address trauma and cultural diversity. I think we need much more effort to hear from people who are in early psychosis treatment, who have been through it, and ESPECIALLY people who did not feel early psychosis was a good fit for them.”
Lack of and need for meaningful engagement with cultural minority communities	Example 1: “I would like to see much more link[age] with local communities to identify problems and barriers and build roles for people within those communities to better understand how to meet [service user] needs.” Example 2: “With respect to [collective] trauma—like that which is carried by entire communities—programs and clinicians need to seek out and value relationships with a range of experts from those communities, not just other clinicians. We need to look at the way in which the community expresses the effects of that trauma (artistically, religiously, medically, socially—as many ways as possible) in a serious way in order to begin to appreciate the impact of the trauma that a community might hold.”
Lack of and need for meaningful engagement with cultural healers and healing practices	“[There is a] lack of knowledge on how to work effectively with—and/or a poverty of power in working with—culture healing professionals (curandera/o, hands-on healers, naturopaths).”