An International Perspective on the Adaptation of CBT Across Cultures

The cutting edge of psychotherapy research today is primarily cross‐cultural and includes two main areas of work. The first area consists of helping/healing approaches that originate within specific cultures, for example, Naikon therapy in Japan, ho'oponopono among Native Hawaiians, curanderismo among Latino people, and many of the specific practices within the world's major religions (e.g., meditation, prayer, recognising blessings, practising compassion, and helping others). The second area involves exploring whether, and if so how, the evidence‐based practices (EBPs) are relevant to the needs of cultures that were not originally in the minds of the EBPs developers. The preceding study by Bennett‐Levy and colleagues is an excellent example of the kind of research needed in this second area: participatory action research that intentionally seeks the expertise of within‐culture members, ideally the counsellors and researchers themselves. The authors ask exactly the kinds of questions that will move the entire psychotherapy field forward towards applications that are helpful to a much wider range of people.     

Adaptation of CBT for Traumatized South African Indigenous Groups: Examples from Multiplex CBT for PTSD

This article describes how Culturally Adapted Multiplex CBT, a treatment that emphasizes somatic processing and emotion regulation, was adapted for a traumatized South African indigenous group, the Sepedi. A model of psychopathology is presented, the Multiplex Model of Trauma-Related Disorder, which depicts the processes that generate multiple comorbidities and prominent somatization in minority, refugee, and other non-Western populations. The nine dimensions of Culturally Adapted Multiplex CBT are discussed, and so too the “cultural adaptation diamond.” Concepts such as “explanatory model bridging” are presented. A culturally sensitive assessment measure of local somatic complaints and cultural syndromes (the Sepedi Symptom and Syndrome Addendum, or Sepedi SSA) is detailed, as well as how CBT techniques were implemented with this group—for example, modification of culturally specific catastrophic cognitions, doing exposure (e.g., interoceptive exposure), teaching attentional control and mindfulness techniques, and teaching “loving kindness.” Case examples with clinical outcomes are provided to further illustrate how Multiplex CBT was adapted for the South African indigenous group.     

Adaptation of CBT for Traumatized Egyptians: Examples from Culturally Adapted CBT (CA-CBT)

In this article we illustrate how CBT can be adapted to a traumatized Egyptian population with Islamic beliefs, giving examples from our adaptation of Culturally Adapted–CBT (CA-CBT) for this cultural group. We discuss a culturally sensitive assessment measure of local somatic complaints and cultural syndromes that was devised based on clinical experience with traumatized Egyptians. We also demonstrate how to normalize symptoms, create positive expectancy about the treatment, and educate about trauma. We give examples of how mindfulness can be adapted for an Egyptian Islamic population, and we describe local religious strategies, such as dhikr (religious chanting), salah (ritualistic prayer), and dua (supplication), that may be used to promote attentional shift from rumination topics and to teach attentional control. We describe how “loving kindness” can be adapted for this group. We outline how to modify culturally generated catastrophic cognitions and how to conduct interoceptive exposure and to create positive re-associations in a culturally sensitive manner. We describe how worry themes are explored and addressed based on a heuristic panic attack–PTSD model; how to teach anger management in a culturally sensitive way; and how to address sleep-related problems in this population. We suggest using cultural transitional “rituals” at the end of the treatment to give patients a sense of closure and a positive feeling of transformation. A case example is presented to illustrate cultural challenges associated with delivering CA-CBT to an Egyptian population. We introduce certain concepts such as cultural grounding and explanatory model bridging, both therapeutic techniques that increase adherence, positive expectancy, and cultural consonance.     

Spontaneous Self‐Practice of Cognitive Behavioural Therapy (CBT) by Aboriginal Counsellors During and Following CBT Training: A Retrospective Analysis of Facilitating Conditions and Impact

Previous cognitive behavioural therapy (CBT) training studies have suggested that therapists who practice CBT strategies on themselves during training may experience professional and personal benefits. However, it has also been reported that some CBT trainees are reluctant to engage in self‐practice. The present study reports an incidental finding from a CBT training study with Aboriginal counsellors: all five counsellors reported that they practiced CBT techniques on themselves without specific encouragement by the trainers to do so. This paper therefore posed three questions: (a) Why—in contrast to some other trainees—did this group choose to apply CBT to themselves? (b) How did they apply it—with what purpose, in what contexts, and which skills? (c) What was the impact of CBT self‐practice? Data from the group's reflections were qualitatively analysed by two of the researchers, and “member checked” by the remainder. Results indicated that the counsellors were motivated to practice CBT on themselves for two principal reasons: the value they placed on CBT, and their personal need resulting from the high number of crises experienced while living and working in their communities. The counsellors reported practicing CBT in a wide variety of contexts as part of their learning. As in previous studies, the impact of CBT self‐practice was that it increased their confidence and competence as therapists. It also appeared to be a valuable burnout prevention strategy. If the results are generalisable, they suggest that self‐experiential training in CBT may be a culturally responsive and adaptive way for Aboriginal counsellors to enhance their learning of CBT skills.     

Contextual Factors for Research on Psychological Therapies for Aboriginal Australians

This paper is to provide a commentary to Can cognitive behavioural therapy (CBT) be effective for Aboriginal Australians? Perspectives of Aboriginal practitioners trained in CBT. It is inspiring that this study has found that CBT can play a useful role in therapy for Aboriginal and Torres Strait Islander people but the outcomes need to be considered with caution. CBT can provide a useful tool when working with Aboriginal and Torres Strait Islander people, but in itself is not adequate for a number of reasons. Firstly, it is not culturally responsive but can be part of an approach that might be culturally appropriate. The authors are compelled at this point to give a history of mental health and Aboriginal and Torres Strait Islander people to provide a background context to the discussion and to illustrate why some psychological approaches such as CBT can only ever be part of the tools that might be used in a broader framework, that is required to address and strengthen Aboriginal and Torres Strait Islander people's well‐being.     

HCV knowledge among a sample of HCV positive Aboriginal Australians residing in New South Wales

Australian Aboriginal and Torres Strait Islanders are overrepresented in both the prevalence and incidence of the hepatitis C (HCV). HCV knowledge has been associated with a range of positive health behaviours. HCV knowledge has previously been investigated as a single construct; however examining different knowledge domains (i.e. transmission, risk of complications, testing and treatment) separately may be beneficial. This study investigated whether having greater HCV knowledge in different domains is associated with self-reported positive health behaviours. 203 Aboriginal people living with HCV completed a survey assessing HCV knowledge, testing and care, lifestyle changes since diagnosis and treatment intent. Respondents’ knowledge was relatively high. Greater knowledge of risk of health complications was associated with undertaking more positive lifestyle changes since diagnosis. Respondents testing and treatment knowledge was significantly associated with incarceration, lifestyle changes since diagnosis and future treatment intentions. This study illustrates the importance of ensuring that knowledge is high across different HCV domains to optimise a range of positive health behaviours of Aboriginal people living with HCV. Future health promotion campaigns targeted at Aboriginal people living with HCV could benefit from broadening their focus from prevention to other domains such as testing and treatment.     

Whole of community suicide prevention forums for Aboriginal Australians

It is well known that Aboriginal Australians are at increased risk of suicide. Contributors to suicide differ for Indigenous and non-Indigenous populations (Westerman, 2003; 2019). This study evaluated whole of community suicide prevention forums conducted across six locations. Attendees were youth (N = 136), service providers (N = 225), and community members (N = 158). The content of the forums was empirically based and, for service providers and community members, covered knowledge of suicide, and depression specific to Aboriginal people, skills relating to working with depressed and suicidal Aboriginal people, and intentions to help an Aboriginal person who is suicidal. Content for youth attendees focused on knowledge of suicide and depression, coping skills, intentions to help a friend, and beliefs about suicide. While the results demonstrated significant gains across most domains, there was a potentiating effect with some skills increases becoming more significant over each phase. This demonstrates that a whole of community approach to Indigenous suicide prevention is required, and that clinical and cultural skills require a longer-term approach for impact and sustainability.     

Internet-Delivered CBT for Children with Specific Phobia: A Pilot Study

Background: Cognitive behavior therapy (CBT) has been shown to be an effective treatment for specific phobia in youth, but not all affected seek or receive treatment. Internet-delivered CBT could be a way to increase the availability of empirically supported treatments. Aims: An open trial was conducted to evaluate Internet-delivered CBT for children with specific phobia. Method: Children (N = 30) aged 8–12, and their parents, with a principal diagnosis of specific phobia were recruited through media advertisement. Participants received six weeks of Internet-delivered CBT with therapist support. The treatment was aimed for the parents and the children, with the first part being only for the parents. The primary outcome measure was the Clinician Severity Rating (CSR), and secondary measures included clinician-rated global functioning and child- and parent-reported anxiety and quality of life. All assessments were made at pretreatment, posttreatment, and three-month follow-up. Results: At posttreatment, there were significant reductions on the CSR, with a large within-group effect size (Cohen's d = 1.0) and 35% of children no longer meeting criteria for specific phobia. Self-report measures from parents and children showed significant effects on anxiety, with small to moderate effect sizes. Effects were maintained at three-month follow-up. Conclusions: Results show that Internet-delivered CBT with therapist support for children with specific phobia has the potential to reduce symptom severity. Randomized controlled trials are needed to further evaluate this treatment format.     

浅谈认知行为治疗在肥胖治疗中的研究与应用

肥胖的治疗方法多种多样,各自具有不同的针对性和疗效特点,如何选择是一个最佳的治疗方案这是一个富有争议的话题。近年来,在肥胖心理学研究成果的基础上,发展了一系列的认知行为治疗方法,也开始应用于肥胖的治疗之中。不少追踪研究表明,该方法对于肥胖的长期疗效较佳,表现出广泛的应用前景。     

Training Aboriginal Practitioners in Cognitive Behavioural Therapy

Comments on an article by Bennett‐Levy and colleagues. This commentary reviews a dissemination of cognitive behavioral therapy (CBT) for Aboriginal Australians, with regard to the strengths of the dissemination effort and areas for future efforts. As an initial step in bringing CBT to a population that has been severely limited in access to evidence based practice, despite a notable need, this study was an important step forward. Feedback from the participatory action research group (n = 5 Aboriginal Australian counsellors) identified CBT elements and adaptations perceived to be particularly effective with Aboriginal Australian clients. Case conceptualization was identified as a potential avenue for further tailoring CBT to the individual needs of clients. Several factor including the success of the dissemination effort, reports that clients shared CBT techniques with their communities, and the skill‐building nature of CBT raised the possibility of future community‐based dissemination.     

Meta-analysis of the efficacy and acceptability of cognitive-behavioural therapy for Arab adult populations experiencing anxiety,depression or post-traumatic stress disorder

A meta-analysis of the literature of cognitive behaviour therapy (CBT) with Arab adult populations experiencing anxiety, depression or post-traumatic stress disorder (PTSD) was conducted. Nine studies (n = 536) met the eligibility criteria. Three of the nine studies (33%) were randomised control trials using waitlist control groups. All studies (100%) reported a statistically significant reduction in psychological symptoms at post-treatment with large effect sizes for anxiety (effect size, 95% confidence interval) (1.44 [1.29, 1.59]), depression (1.26 [1.16, 1.35]) and PTSD (2.08 [1.94, 2.23]). Six out of the nine studies (67%) collated follow-up data and reported that reductions of psychological symptoms were maintained at follow-up. An average dropout rate of 26% indicated good overall acceptability. Five out of nine (55%) of the trials reported diagnostic remission rates and of those trials the mean remission rate was 31%). Five of the nine eligible studies (55%) delivered remotely via Internet or telephone were found to have similar effect sizes as face-to-face CBT. The current meta-analysis indicates the potential of CBT, delivered either face-to-face or via internet, as efficacious and acceptable interventions for the treatment of anxiety, depression and PTSD for Arab adult populations.     

University students’ views about compatibility of cognitive behaviour therapy (CBT) with their personal,social and religious values (a study from Pakistan)

Cognitive behaviour therapy (CBT) in its current form might not be applicable in non Western cultures. Differences between Western and non Western cultures have been reported widely. Psychotherapy was developed in the West and is underpinned by many beliefs which might be specific only to the Western culture. However, in order to modify CBT, we need to understand whether the concepts associated with the CBT might cause conflicts among people who receive therapy. This study explored the beliefs of the university students in Pakistan to find out if the concepts underpinning CBT are consistent with the personal, family, socio-cultural and religious values of the university students. Discussions were held with University students in Rahim Yar Khan, Pakistan. Students were given information on various aspects of the CBT and were asked to rate their agreement with these concepts on a visual analogue scale. There was little disagreement for the principles of CBT for personal values, while some disagreement existed for religious values. This study highlights the value of assessing peoples’ beliefs about acceptability of CBT in non Western cultures. Students in Pakistan felt that the principles of CBT are consistent with their belief system in most areas. However, the value system of students might not be representative of the rest of the population.     

Cognitive-Behaviour Therapy and Psychological Treatments in Australia

In this article, we focus on the various recent healthcare reforms in Australia and their implication for cognitive behavioural therapy (CBT). Specifically, we focus on three areas relevant to CBT in Australia. After discussing the background of mental healthcare in Australia, we highlight the impact that recent health reforms have had on the foregrounding of evidence-based treatment, with CBT as a focus. Second, we consider the limitations to therapy in this country, in particular the 10-session limit within the Medicare system acting as a limitation on therapy. Finally, we discuss the impact of the acceptance of psychological treatment, and mental illness more generally in Australia.     

Can CBT Be Effective for Aboriginal Australians? Perspectives of Aboriginal Practitioners Trained in CBT

The objective of the study was to investigate whether high and low intensity versions of cognitive behaviour therapy (CBT) might be an effective therapeutic approach for enhancing the mental health of Aboriginal Australians. Five university‐educated Aboriginal counsellors received in‐depth training in CBT. Over the following year, they used CBT strategies with their clients, and met 10 times as a participatory action research group. The group addressed three key questions: (a) Does CBT appear to be useful for Aboriginal Australians? (b) If so, what elements of CBT are perceived to be effective? (c) What adaptations might be made to CBT to enhance its effectiveness with Aboriginal Australians? The resulting qualitative data were transcribed and analysed. Counsellors perceived CBT to be very useful for their Aboriginal clients and for themselves. They reported that it enhanced their clients' well‐being, their own clinical skills, and their own well‐being, and it reduced burnout. The qualities of CBT that were perceived to be effective were its adaptability, pragmatic here‐and‐now approach, capacity for low‐intensity interventions, safe containing structure, promotion of self‐agency, and valuable techniques. It was suggested that the prime requirement for adaptations to CBT were that they would need to fit different social and cultural contexts.     

A Cultural Adaptation of Dialectical Behavior Therapy in Nepal

Growing evidence exists on the potential for adapting evidence-based interventions for low- and-middle-income countries (LMIC). One opportunity that has received limited attention is the adaptation of psychotherapies developed in high-income countries (HIC) based on principles from LMIC cultural groups. Dialectical behavior therapy (DBT) is one such treatment with significant potential for acceptability in South Asian settings with high suicide rates. We describe a tri-phasic approach to adapt DBT in Nepal that consists of qualitative interviews with major Nepali mental health stakeholders (Study 1), an adaptation workshop with 15 Nepali counselors (Study 2), and a small-scale treatment pilot with eligible clients in one rural district (Study 3). Due to low literacy levels, distinct conceptualizations of mind and body, and program adherence barriers, numerous adaptations were required. DBT concepts attributable to Asian belief systems were least comprehensible to clients. However, the 82% program completion rate suggests utility of a structured, skills-based treatment. This adaptation process informs future research regarding the effectiveness of culturally adapted DBT in South Asia.     

Aboriginal perceptions of social and emotional wellbeing programs: A systematic review of literature assessing social and emotional wellbeing programs for Aboriginal and Torres Strait Islander Australians perspectives

Australian Aboriginal and Torres Strait Islander communities have been targets of social and emotional wellbeing programs for many years. However, the few health-care programs and services that are evaluated rarely provide insight into the participants' perspectives of program success or failure. This systematic review assessed 33 social and emotional wellbeing programs across Australia to better understand what Aboriginal community members think about the programs and how they could be improved. Results highlighted the interesting and valuable insights provided by Aboriginal participants, including what kinds of program activities and approaches are most suitable, what program characteristics are successful or desired, and their experiences of wellbeing change before and after program participation. They likewise voiced opinions about poorly received programs, culturally inappropriate services and negative experiences. This review highlighted how health and wellbeing programs must better engage Aboriginal and Torres Strait Islander clients to ensure that services are culturally safe, holistic, integrate appropriate staffing, include culturally relevant activities and value patient/participant experiences. These findings have significant implications for the health and wellbeing sector; specifically, research, policy, program design and implementation, evaluation methods, and self-determination.     

The Effects of Transdiagnostic Group CBT for Anxiety on Insomnia Symptoms

Insomnia is a common feature among individuals with anxiety disorders. Studies of cognitive behavioral therapy (CBT) for anxiety report moderate effects on concomitant insomnia symptoms, but further research is still needed especially toward understanding how CBT for anxiety renders beneficial effects on insomnia. The current study examined changes in insomnia symptoms reported by 51 Veterans who participated in a group-based transdiagnostic CBT for anxiety intervention. In addition, insomnia symptoms were examined in relation to symptoms of general distress (GD), anhedonic depression (AD), and anxious arousal (AA) pre- to post-treatment. Results revealed a small, though statistically significant (p < .05) beneficial effect on insomnia symptoms. When changes in GD, AD, and AA were simultaneously examined in relation to changes in insomnia, change in AA was the only significant predictor of insomnia symptoms. The current study highlights the role of AA in the relationship between anxiety disorders and insomnia and demonstrates that reductions in insomnia during transdiagnostic CBT for anxiety can be largely attributed to changes in AA.