Why adapt cognitive behaviour therapy?

Cognitive behaviour therapy was developed by Beck as a structured, present-oriented therapy for depression. It was designed to solve current problems by targeting and modifying unhelpful thinking patterns and belief systems using the cognitive model (Beck, Reference Beck1964). Automatic thoughts and schemas were explained by Clarke and colleagues (Clark et al., Reference Clark, Beck and Alford1999). Over time, benefits of CBT have been realized for many conditions like anxiety disorders, borderline personality disorder and psychosis through case series, RCTs and meta-analyses.

In CBT, the therapist explores the person's beliefs and experiences to elicit cognitive biases, emotions and behaviours to develop a formulation and treatment plan. Culture influences an individual's life experiences, belief systems and assumptions. As a result, it impacts on the psychopathology of mental illness. Therefore, it follows that culture shapes beliefs about health and illness, pathways into care, and trust in services.

Figure 1. Role of culture in CBT model. Reprinted with permission from Rathod et al. (Reference Rathod, Kingdon, Pinninti, Turkington and Phiri2015).

Cultural differences in life philosophies (Okasha and Okasha, Reference Okasha and Okasha2000) are well documented. The risk of continuing to practise CBT in different cultural groups without adaptation can be disengagement and poor outcomes of therapy (Rathod et al., Reference Rathod, Kingdon, Smith and Turkington2005). Additionally, it may affect the therapeutic relationship with the therapist which is central to any therapeutic intervention, again, leading to poor outcomes. The therapist may feel relatively incompetent (Rathod et al., Reference Rathod, Kingdon, Pinninti, Turkington and Phiri2015) as a consequence.

CBT is an evidence-based, pragmatic, collaborative therapy that emphasizes the critical role of cognitions, emotions and behaviours and therefore lends itself to adaptation while maintaining fidelity to the core CBT techniques (Rathod et al., Reference Rathod, Kingdon, Pinninti, Turkington and Phiri2015). Often, people from different cultural backgrounds struggle to trust the health systems, mainly mental health services (Schwarzbaum, Reference Schwarzbaum2004), especially in developed countries. The fundamental principles of CBT based on engagement and working together, can help diffuse the mistrust if the therapy appeals to the individual's cultural values.

A further argument is that CBT addresses relationships and not only cognitions and beliefs. The cognitive model of CBT suggests that the focus of therapy is on an individual's relationship (1) with self, (2) with others and (3) with the future. In many Eastern cultures family and community play a central role and are often sources of support, although changing values in many non-Western cultures might mean the nature of relationships is changing. Therefore CBT lends itself to successful adaptation, using the family and community networks as collaborators in the process where appropriate.

Frameworks for cultural adaptions of interventions

Any attempts to adapt therapy to culture have challenges. There could be a tendency to over-generalize and stereotype to cultures and subcultural groups. Maintaining fidelity to the core intervention while adapting to culture is an important consideration. Despite the challenges, local adaptations are occurring globally, based on therapists’ experiences and local population needs with some benefits. Examples include studies by Carter and colleagues (Reference Carter, Sbrocco, Gore, Marin and Lewis2003), Hinton and colleagues (Reference Hinton, Pham, Tran, Safren, Otto and Pollack2004), Kubany and colleagues (Reference Kubany, Hill and Owens2003), Patel and colleagues (Reference Patel, Araya, Chatterjee, Chisholm, Cohen and De Silva2007), Rahman et al. (Reference Rahman, Malik, Sikander, Roberts and Creed2008), Rojas et al. (Reference Rojas, Fritsch, Solis, Jadresic, Castillo and González2007) and Nagel et al. (Reference Nagel, Robinson, Condon and Trauer2009).

Numerous adaptation frameworks and guidance have been developed over time to aid this process. The first adaptation framework was published by Bernal and colleagues (Reference Bernal, Bonilla and Bellido1995), using Latino participants and based on the ecological validity model for cultural adaptation. This framework consists of eight elements: language, persons, metaphors, content, concepts, goals, methods, and context.

Bernal's model was further developed and adapted by Domenech Rodríguez and Weiling (Reference Domenech Rodríguez and Weiling2004), and then by Hwang and colleagues (Reference Hwang, Wood, Lin and Cheung2006) to extend its usability in different groups. Adaptation frameworks were developed by Tseng (Reference Tseng1999) describing the influence of culture on therapies. Resnicow and colleagues (Reference Resnicow, Soler, Braithwait, Ahluwalia and Butler2000) described two levels of cultural adaptation: surface structure adaptations and deep structure adaptations, while Leong and Lee (Reference Leong and Lee2006) developed an integrative and multi-dimensional cultural accommodation model.

Lau (Reference Lau2006), and later Barrera and Castro (Reference Barrera and Castro2006), developed adaptations consisting of systematic phases and a heuristic framework with specific emphasis on developing mechanisms that would allow for both measuring and evaluating the impact of cultural adaptations using specific outcome measures.

The models described above have similarities in the dimensions of adaptation, but differ in the level of detail, including the different cultural groups for which they were described. They have limitations in relation to cultures (Rathod et al., Reference Rathod, Kingdon, Pinninti, Turkington and Phiri2015) other than Asian and Hispanic groups. Hays and Iwamasa (Reference Hays and Iwamasa2006) attempted to address this. However, none of the previous adaptation frameworks has been tested through RCTs.

An evidence-based methodology to cultural adaptation of CBT

Our group has developed an adaptation framework that can be applied to CBT in different cultural groups. The adapted intervention has been evaluated through randomized trials (Naeem et al., Reference Naeem, Waheed, Gobbi, Ayub and Kingdon2010; Naeem et al., Reference Naeem, Gul, Irfan, Munshi, Asif, Rashid, Khan, Ghani, Malik, Aslam, Farooq, Husain and Ayub2015a,b; Rathod et al., Reference Rathod, Phiri, Harris, Underwood, Thagadur, Padmanabi and Kingdon2013). Currently, this methodology and framework is being used to adapt CBT in Morocco (Fatema-Zahra El Rhermoul et al., Reference El Rhermoul, Naeem, Kingdon, Hansen and Toufiq2018), the Middle East and China (Li et al., Reference Li, Li, Luo, Liu, Liu, Lin, Liu, Xie, Hudson, Rathod, Kingdon, Husain, Liu, Ayub and Naeem2017).

The adaptation framework has been developed using a staged process. The first step has involved information gathering from literature and used the qualitative methodology, underpinned by the ethnographic approach. The process has ensured a co-production model with experts by experience, carers, lay members of minority communities and clinicians to develop the adaptation framework that is relevant. Emergent themes have informed development of the guidance used to deliver culturally adapted CBT that is personalized to an individual's culture. The therapy material or manual is then translated and culturally adapted in light of the guidance developed from the qualitative analyses and existent literature. The adapted therapy is field tested and further refinements are made based on the findings (Naeem et al., Reference Naeem, Phiri, Nasar, Gerada, Munshi, Ayub and Rathod2016).

Table 1. Staged process of developing adaptation framework (Naeem et al., Reference Naeem, Phiri, Nasar, Gerada, Munshi, Ayub and Rathod2016)

Foci of adaptation

Adaptation in our work has focused on three fundamental areas of delivery, which we refer to as the ‘Triple-A’ principle:

1. I. Awareness of relevant cultural issues and preparation for therapy. This can be further subdivided into: (a) culture and culture-related issues including religion and spirituality, family and community, and language and communication; (b) system and environmental aspects including individual capacity and circumstances, systems of support, services, and helpseeking pathways into care; and (c) cognitive biases and unhelpful beliefs that are directly related to the problem and its treatment.

2. II. Assessment and engagement.

3. III. Adjustments in therapy.

These areas and sub-areas are further discussed below in the framework of adaptation.

Framework for cultural adaptation of CBT

The process of adaptation starts with preparation for the therapy, i.e. pre-engagement phase as access to therapy, its delivery and most importantly availability for a given culture is as important as the actual modification of the intervention. The adaptation framework then progresses to engagement and assessment, followed by the therapy using relevant cultural adaptations to improve outcomes.

Rathod and colleagues (Reference Rathod, Kingdon, Pinninti, Turkington and Phiri2015) have developed a framework that encompasses the Triple-A principles for cultural adaptation of CBT focusing on the following aspects:

1. (i) Philosophical orientation;

2. (ii) Practical considerations of societal and health system-related factors;

3. (iii) Technical adjustments of methods and skills; and

4. (iv) Theoretical adaptations of concepts.

We have developed this adaptation model based on our work, using descriptions initially described by Tseng and colleagues (Reference Tseng, Chang and Nishjzono2005) and modifying them. The key principle is that every individual has a unique culture that is influenced by their wider culture, sub-culture and further developed through unique life experiences. There must be flexibility in applying the culturally adapted therapy, and clinicians should be aware of their own biases, and propensity to stereotype when working with people from minority groups. Below we briefly describe the framework that is explained in detail with case examples in the manual (Rathod et al., Reference Rathod, Kingdon, Pinninti, Turkington and Phiri2015).

Philosophical orientation or differences in world view

The fundamental view of life can be different between individuals and different cultures to a degree, and this can affect perceptions of health and illness, and relationship with services and professionals, including treatment and goals of therapy. Rathod and colleagues (Reference Rathod, Kingdon, Pinninti, Turkington and Phiri2015) describe philosophical orientation along the following constructs:

1. a. Acculturation – acculturation is the process of adjustment that involves integration of the original and new cultural values and attitudes. This can occur during the period of prolonged contact with the host culture after immigration or internal movement in countries. The blending of cultural values is often a gradual process (Garcia and Zea, Reference Garcia and Zea1997), and can occur over several generations. The process of acculturation can result in integration, assimilation, separation, and/or marginalization – describing different trajectories of individuals influencing behaviours when interacting with others (Berry, Reference Berry2005).

An individual can present with a mixture of different attitudes in different phases of life, through the influences of positive and negative life experiences and other factors. Figure 2 describes this. Understanding of an individual's level of acculturation helps to understand how to engage with them and develop explanations in therapy based on their value systems.

Figure 2. Oscillation of an individual's cultural values: Shanaya Rathod and David Kingdon (2009). CBT across cultures. Psychiatry 8, 370–371. Copyright ©2009 Elsevier Ltd; printed with permission.

1. b. Beliefs and attributions to illness: culture influences beliefs around health and attributions to illness. In many cultures, the mind and body are viewed as one. Therefore depression and other mental illnesses can present as somatic symptoms. As an example, the distress and symptoms of depression can be attributed to neurasthenia (meaning weakening of nerves) by some in the Chinese culture (Kleinman, Reference Kleinman1982). McCabe and Priebe (Reference McCabe and Priebe2004) discussed that biological explanations were much more frequently cited by Caucasians than African Caribbean and West Africans when describing symptoms of mental illness. Our research found key attributions around ‘previous wrongdoing’, supernatural beliefs, and social and biological factors in the sample of participants from South Asian Muslim, Black African and African Caribbean populations. Other attributions like the use of drugs and being arrested have also been quoted (Rathod et al., Reference Rathod, Phiri, Kingdon and Gobbi2010). Typical religious attributions can include ‘will of God or obeah (casting of an evil eye)’ by another.

Stigma plays an important role in cultural attributions to illness. Shame is often associated with stigma. Women can be more affected than men, especially within the South Asian Muslim communities. This gender difference can be attributed to gender bias including role expectations, rights and responsibilities.

In relation to cognitive biases, having a good cultural understanding of the individual's background may be helpful when considering cultural adaptations in relation to their assumptions, beliefs, norms and illness attributions. An understanding of the attributions helps clinicians in engaging people and addressing their distress.

1. c. Help-seeking behaviours defining pathways into care: an individual's attributions to health, illness and beliefs about health and illness often determine help-seeking pathways into care. Mistrust or trust for local services also dictates the speed of access by different communities. Some individuals may choose to seek help from their cultural or traditional healers first or in addition to conventional services. Understandably, delays in presenting to appropriate services may occur and prolong the duration of untreated symptoms.

One of the key predictors of prognosis in psychosis is duration of untreated psychosis. In recognition of this key prognostic factor, the access and waiting time standard has been introduced in the UK (NHS England, 2015) and integrated care pathways have been developed that ensure early access to services and evidence-based interventions for first episode psychosis patients (Rathod et al., Reference Rathod, Garner, Griffiths, Dimitrov, Newman-Taylor, Woodfine, Hansen, Tabraham, Ward, Asher, Phiri, Naeem, North, Munshi and Kingdon2016). In Sadiq's case, the duration of untreated psychosis was 6 months before he presented to services. This example demonstrates how help-seeking pathways into care can influence access to services and awareness of how culture influences these pathways can help clinicians in understanding differing orientation to care and health.

Table 2. Cultural barriers to accessing therapy (from Rathod et al., Reference Rathod, Kingdon, Pinninti, Turkington and Phiri2015); reproduced with permission from John Wiley and Sons)

1. d. Cultural orientation towards psychotherapy: cultural beliefs regarding interventions can define whether people from certain cultural groups will engage with therapies like CBT.

Practical considerations

There is a complex relationship between religion, politics and health services in any country. In some LMICs, social factors, like poverty, urbanization, internal migration and lifestyle changes, are moderators of the burden of mental illness and service provision (Rathod et al., 2017). It helps if clinicians and therapists understand to what extent policies promote integration with the other sectors such as justice, social care and development of services to ensure a more comprehensive (prevention, promotion and treatment) and holistic approach to the delivery of mental health services and experiences of individuals in the system.

Technical adjustments

This involves adjustment of methods, including the mode and manner of therapy and various clinical issues within the therapy for individuals of different backgrounds. Technical adjustment involves an understanding of:

1. a. Setting and environment of therapy: therapists use clinic setting or individual's homes and in some circumstances meet at an external venue. Meeting people in their homes gives the opportunity to see their home environments, neighbourhoods, social supports and meet family members. In either situation, the environment should be culturally welcoming; information should be available in appropriate languages and if needed interpreters should be used (Rathod and Naeem, Reference Rathod and Naeem2012).

   In many LMIC distance and transport can be an issue. Individual adjustments including length and number of sessions need to be made. Technology can be an enabler, although connectivity can be a problem.

2. b. Therapeutic relationship: the therapeutic relationship or alliance is accepted to be one of the critical factors, if not the crucial factor, in determining the outcome of psychotherapy (Warwar and Greenberg, Reference Warwar and Greenberg2000). Therapists need to strive to build the therapist alliance at every stage of therapy including:

   1. 1. Engagement and assessment;

   2. 2. Individualized collaborative case formulation;

   3. 3. Effective sequential interventions based on the case formulation;

   4. 4. Relapse prevention and termination.

First impressions are important (Anez et al., Reference Anez, Paris, Bedregal, Davidson and Grilo2005). The personal style of the therapist can play a role in the development of therapeutic alliance. Some suggest (Taylor et al., Reference Taylor, Beatriz-Gambourg, Rivera and Laureano2006) a more personal and friendly style – which conveys warmth and trust – in the first session as helpful in fostering a therapeutic alliance.

Limited and measured personal disclosure in a safe manner is often a way of gaining trust. One may ask ‘how would you know how I feel?’. Therapists can answer using personal experience: ‘I do not as your experience is unique to you. However, I do know that we all have times of distress and how we feel during these times’.

Often limited self-disclosure is about building trust and respect more than the disclosing personal information.

1. c. Therapeutic style: Western therapists use the rational, collaborative and cognitive approaches to understanding the nature and origin of problems and coping strategies to deal with them. Eastern therapies stress the importance of experience and use meditation and mindfulness techniques. Therefore, there may be a mismatch of cultural values in therapy. However, an experienced therapist can use useful techniques that suit the individual by suitable adaptations.

2. d. Family structures and goals: in many cultures, families function as a unit and family members are closely involved in the therapeutic process. Families can be used as a strength as they can help engage individuals, help with homework and also provide the social support that aids recovery. The adverse impact of complex relationships also needs acknowledgment.

3. e. The role of religion: spiritual development is a vital part of all cultures (Laungani, Reference Laungani2004). Sometimes ignorance or interpretation of spiritual experiences as manifestations of psychopathology and lack of confidence can occur, which results in the key issue not being addressed. Clinicians in one study reported feeling disempowered when faced with the subject of religion and spirituality. The influence of religion and spirituality remains strong in Eastern cultures despite Westernization and acculturation (Williams et al., Reference Williams, Hean and Beverly2006). Some services flourish through close collaboration with religious institutions.

Theoretical modifications

Some changes in theoretical concepts need to be made for the best fit for an individual and their cultural strength. This can involve the use of different ways of explaining concepts. Some examples are cited below:

1. (a) Body and mind: in many cultures, the body and mind are considered one entity. The discussions used in therapy around the relationship between physical symptoms and mental illness reflect the holistic view of health and appreciation of this concept varies between cultures. Understanding what the individual values can be helpful in deciding explanations used in therapy.

2. (b) Self and ego boundaries: in some individuals from Eastern cultures, boundaries between self, family and society are narrow and influence interactions. For instance, the interdependent relationships with family and communities often determine how an individual seeks help.

3. (c) Individuality and collectiveness: when a therapist is insensitive to cultural norms and cultural explanations of idioms of distress, there could be obstacles in the cognitive and behaviour change processes, especially if the explanations used for change do not line with cultural values. In collectivist cultures, there is an interdependence with group members and the self is defined by group identity. Individuals prioritize communal needs over their own. In many Western cultures, the self is autonomous and independent of groups. Priority is given to personal goals, and the need often involves exchange relationships, i.e. ‘what's in this relationship for me?’.

Collaborative empiricism underpinning psychological interventions can be a challenge when working with people from LMIC. Some literature suggests that individuals take on a passive role as they probably would with their traditional healer or ‘guru’. However, if a therapist takes an overtly directive style they may be viewed by individuals as controlling (an agent of a dominant culture). Some individuals may respond better to a structured and prescriptive approach to therapy (Iwamasa et al., Reference Iwamasa, Hsia, Hinton, Hays and Iwamasa2006). Similarly, in some, exploration of opinions about the problem and collaboration may lead to doubts about the therapist's competencies, particularly when the locus of control is believed to be external and the individual has a desire for a quick fix. A paternalistic attitude can sometimes be more therapeutic.

Main points

1. (1) Culturally adapted CBT shows better results in individuals from different cultural groups.

2. (2) Adaptation of therapy requires a robust methodology.

3. (3) Every individual has a unique culture that is influenced by their wider culture, sub-culture and further developed through unique life experiences.

4. (4) There must be flexibility in applying the culturally adapted therapy, and clinicians should be aware of their biases, and propensity to stereotype when working with people from minority groups.