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.     

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.     

Acceptance and Mindfulness Techniques as Applied to Refugee and Ethnic Minority Populations With PTSD: Examples From "Culturally Adapted CBT"

In this article we illustrate how we utilize acceptance and mindfulness techniques in our treatment (Culturally Adapted CBT, or CA-CBT) for traumatized refugees and ethnic minority populations. We present a Nodal Network Model (NNM) of Affect to explain the treatment's emphasis on body-centered mindfulness techniques and its focus on psychological flexibility. We explain the definition of mindfulness that guides our treatment, and we outline a typology of mindfulness states and show how many of the techniques in our treatment can be analyzed by these categories. We argue that acceptance and mindfulness are therapeutic for refugees and minority populations for several reasons. These include their increasing psychological flexibility, decreasing somatic distress, decreasing rumination, serving as emotion regulation techniques, decreasing the attentional bias to threat, and forming part of a new adaptive processing mode (which in CA-CBT centers on psychological flexibility). We describe the specific ways we teach acceptance and mindfulness with Latino and Southeast Asian refugee populations and present case examples of the treatment of a traumatized Latino and Cambodian patient.     

Parameters for Creating Culturally Sensitive CBT: Implementing CBT in Global Settings

The current article is a commentary on the article, “A Common Elements Approach for Adult Mental Health Problems in Low- and Middle-Income Countries,” which describes a form of transdiagnostic CBT and its implementation among a highly traumatized Burmese and Iraqi group. Murray et al.’s (this issue) article is one of several new studies indicating the efficacy of CBT in global contexts. In this commentary, we suggest a set of parameters to create culturally sensitive CBT in global settings in a way to maximize efficacy and effectiveness. When applicable, we will discuss ways in which these parameters are illustrated by Murray et al. in this pilot study. These parameters can be used more generally to design culturally sensitive CBT studies in global contexts and to evaluate such studies. Some examples of these parameters are culturally appropriate framing of CBT techniques, assessing and addressing key local complaints (e.g., somatic symptoms) and local catastrophic cognitions, and incorporating key local sources of recovery and resilience.     

Psychological Healing in Pakistan: From Sufism to Culturally Adapted Cognitive Behaviour Therapy

The current paper provides an overview of the cultural and religious background of Pakistan; the current situation of mental health in Pakistan with special emphasis on cultural adaptation of cognitive behaviour therapy (CBT) in Pakistan. In the context of Sufism- Islamic Mindfulness, it is interesting to note that it has been easy to explain the concepts of CBT to the therapists and clients in Pakistan, but the process to culturally adapt CBT in Pakistani culture, had to be based on patience while generating evidence for it. Our group has taken the responsibility to do that and so far, have been successful in the endeavours pertaining to research and service development, described in this paper.     

Culturally Adapted Psychosocial Interventions for Schizophrenia: A Review

Recent research examining the potential efficacy of culturally adapted interventions for various mental disorders illustrates increasing interest in the integration of cultural perspectives into mental health systems. Despite recent evidence demonstrating that culturally adapted interventions may be more effective than a one-size-fits-all approach, few psychosocial treatments for schizophrenia consider cultural factors that may enhance their efficacy with diverse populations. The aim of this review is to discuss the empirical evidence examining the potential utility of culturally adapted group interventions for schizophrenia, as a means to encourage further work and expansion in this area. Specifically, this article provides an in-depth review of the empirical literature on culturally adapted psychosocial interventions for individuals with schizophrenia and their family members, with a focus on group-based interventions. This review is followed by a discussion of a few cultural constructs that may impact patient and family member functioning, and therefore may be important to address in psychosocial treatments for schizophrenia. Finally, we end this review with a broad discussion of research limitations and potential areas for additional research, clinical implications for adapting EBTs to better address cultural concerns, and a case vignette to illustrate how cultural considerations can be integrated into a traditional multifamily group therapy approach.     

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.     

Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.     

Cultural Adaptation of CBT for Aboriginal Australians

This paper provides a commentary and provides international context to the research conducted by J. Bennett‐Levy et al. Cognitive Behavioural Therapy (CBT) is a highly structured psychological treatment that has unprecedented empirical validation relative to other approaches to therapy. Despite the wealth of evidence supporting its use, the case for CBT is far less compelling for ethnic minority groups. There is however a growing body of international literature supporting the notion of adaptation of CBT for these groups. The research by J. Bennett‐Levy et al. represents a positive step toward validating CBT for use with Australia's indigenous people that is likely to shape the future direction of research in this field. Suggestions are made regarding the next logical empirical steps in this important area of investigation.     

Aboriginal Practitioners Offer Culturally Safe and Responsive CBT: Response to Commentaries

We appreciate the valuable commentaries that have been provided for our paper “Can CBT be effective for Aboriginal Australians? Perspectives of Aboriginal practitioners trained in CBT.” The international authors identify how CBT, with adaptations by culturally responsive practitioners can be of value for non‐Western and Indigenous peoples. The commentary by Australian psychologists Dudgeon and Kelly questions the value of CBT for Indigenous Australians, terming it a “Western therapy” that is “culturally unresponsive” and “culturally blind.” They also critique the methodology of the study. We argue that CBT can be adapted by culturally competent practitioners to be culturally safe in Australia, as elsewhere. Cultural safety is mostly a function of the therapist, not the therapy. In the Bennett‐Levy et al. (2014) study, CBT was delivered in a culturally responsive way by Aboriginal counsellors within their own communities. CBT is a particularly adaptable and versatile therapy, and embodies principles of empowerment and self‐determination that are central to Indigenous social and emotional well‐being. We are concerned that CBT, which has strong empirical support and has been adapted elsewhere for a range of cultures, including Indigenous cultures, may be being denied to Indigenous Australian clients. There is considerable opportunity to evaluate the effectiveness and versatility of CBT, and variations of its mode of delivery, for all Australians.     

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) Adapted as a School-Based Anxiety and Depression Prevention Program: An Initial Cluster Randomized Wait-List-Controlled Trial

Anxiety and depression are common debilitating conditions that show high comorbidity rates in adolescence. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich-May et al., 2018) is one of the few existing resources aimed at applying transdiagnostic treatment principles across the core dysfunctions implicated in the development of both anxiety and depression using a single protocol. This is the first known controlled study to examine the efficacy of the UP-A adapted as a nine-session universal preventive intervention program delivered in a school setting. A total of 151 students (mean age: 15.05) participated in this randomized wait-list-controlled trial conducted in Madrid, Spain. An unexpected decline in anxiety and depression levels from pre- to posttreatment and follow-up was found in both groups (p = .009, d = –0.22), and overall differences between conditions did not reach significance. Exploratory analyses of baseline emotional symptom severity as a potential predictor trended toward a significantly greater decrease in symptoms of depression for those with greater baseline emotional symptoms in the UP-A group compared to the wait-list-control group. Future trials with larger samples are justified to estimate the effect of the UP-A adapted as a selective prevention program for anxiety and depression.     

A Pilot Study of Culturally Adapted Cognitive Behavior Therapy for Hispanics with Major Depression

The purpose of this study was to evaluate a culturally adapted cognitive-behavioral treatment (CBT) for major depression among Hispanics in primary care. Cultural adaptations were applied based on a range of cultural considerations described in the literature. Fifteen Hispanic primary care patients with major depression were enrolled. All participants received the 12-session intervention and completed baseline, posttreatment, and 6-month follow-up assessments. Four participants (27%) dropped out of the treatment. Analyses focused on changes from baseline functioning using a Wilcoxon Signed Rank Test. Results showed significant reductions in depressive, anxious, and somatic symptoms at posttreatment and 6-month follow-up. Mean reduction of depressive symptoms at posttreatment was 57%. Findings of acceptable treatment retention rates and clinically meaningful reductions in depressive symptoms showed promise for this intervention to treat Hispanics with major depression. Future studies should conduct a more rigorously controlled evaluation of this intervention.     

Adaptation of the Coping With Stress Course for Black Adolescents in Low-Income Communities: Examples of Surface Structure and Deep Structure Cultural Adaptations

Black adolescents in low-income communities are at increased risk of developing mental health problems due to the impact of cumulative poverty-related stressors and racial discrimination, yet Black youth have relatively low rates of mental health service utilization, resulting in significant unmet need. The Coping With Stress (CWS) Course is an evidence-based, cognitive behavioral intervention that has been shown to reduce the incidence of anxiety, mood, and conduct problems among predominantly White samples, as well as Asian and Latinx youth. In the past 25 years since the CWS Course was introduced, Black adolescents have either been severely underrepresented or conspicuously absent from program evaluation research on the CWS Course, with few exceptions. The purpose of this article is threefold: (1) to justify the need for cultural adaptations to the CWS Course for Black adolescents from low-income communities, (2) to describe the scientific basis for the specific surface structure and deep structure modifications made to the culturally adapted version of the CWS Course, known as Resilient In spite of Stressful Events or RISE, and (3) to illustrate the deep structure adaptations with a vignette drawn from implementation of the RISE program with Black adolescents in a low-income, urban community.     

Examining Hope as a Transdiagnostic Mechanism of Change Across Anxiety Disorders and CBT Treatment Protocols

Hope is a trait that represents the capacity to identify strategies or pathways to achieve goals and the motivation or agency to effectively pursue those pathways. Hope has been demonstrated to be a robust source of resilience to anxiety and stress and there is limited evidence that, as has been suggested for decades, hope may function as a core process or transdiagnostic mechanism of change in psychotherapy. The current study examined the role of hope in predicting recovery in a clinical trial in which 223 individuals with 1 of 4 anxiety disorders were randomized to transdiagnostic cognitive behavior therapy (CBT), disorder-specific CBT, or a waitlist controlled condition. Effect size results indicated moderate to large intraindividual increases in hope, that changes in hope were consistent across the five CBT treatment protocols, that changes in hope were significantly greater in CBT relative to waitlist, and that changes in hope began early in treatment. Results of growth curve analyses indicated that CBT was a robust predictor of trajectories of change in hope compared to waitlist, and that changes in hope predicted changes in both self-reported and clinician-rated anxiety. Finally, a statistically significant indirect effect was found indicating that the effects of treatment on changes in anxiety were mediated by treatment effects on hope. Together, these results suggest that hope may be a promising transdiagnostic mechanism of change that is relevant across anxiety disorders and treatment protocols.     

Culturally Sensitive Risk Behavior Prevention Programs for African American Adolescents: A Systematic Analysis

The current review conducted a systematic assessment of culturally sensitive risk prevention programs for African American adolescents. Prevention programs meeting the inclusion and exclusion criteria were evaluated across several domains: (1) theoretical orientation and foundation; (2) methodological rigor; (3) level of cultural integration; (4) program target or domain (e.g., schools, communities, families); (5) outcome change level assessed (e.g., addressing change in beliefs/values or behaviors); and (6) program effects on risk behaviors. Thirteen studies (N = 13) with adolescent participants ranging from 10 to 18 years were identified and evaluated. Analyses suggested that more effective culturally sensitive risk prevention programs included the following: (1) a clearly articulated theoretical orientation, which utilized both universal (e.g., behavioral theories) and culturally specific (e.g., Africultural theories) frameworks; (2) a rigorous methodological design (e.g., inclusion of control group, utilization of program manuals, valid and reliable study measures); (3) an integration of culture at multiple levels (e.g., accessibility, delivery, and content) of programming; (4) consideration of the influence of multiple contexts and domains (e.g., family, community, school); (5) multiple behavior change outcomes (e.g., behaviors, relationships, values); and (6) sustained program effects over time. Recommendations for increasing the effectiveness and efficacy of culturally sensitive prevention programs are discussed.     

Positive CBT: From Reducing Distress to Building Success

Recent decades have witnessed the development of competency-based, collaborative approaches to working with clients. This article reveals how cognitive behavioral therapy (CBT) becomes Positive CBT, with a shift in the focus of therapy from what is wrong with clients to what is right with them, and from what is not working to what is. The concept of Positive CBT, aimed at improving the well-being of clients and their therapists, draws on research and applications from Positive Psychology and Solution-Focused Brief Therapy. A FBA of exceptions to the problem and the ‘upward arrow’ instead of the ‘downward arrow’ technique are two of the many practical applications of Positive CBT, described in this article. Further research is necessary due to its recent development.     

Development of a Culturally Responsive Group Counseling Model for Mexican American Adolescents

This article discusses a group counseling model specifically targeted for Mexican American adolescents with behavior problems including substance abuse. An integrated model is proposed, with the model assumptions clearly articulated and specific therapeutic goals addressed in a culturally responsive manner. Foci of the model are ethnic identity, affective expression, and life choices. Preliminary findings indicate that the youths are retained in the groups at a higher rate than predicted. To live in the Borderlands means you are neither hispana India negra espanola ni gabacha, eres mestiza, mulata, half-breed caught in the crossfire between camps while carrying all five races on your back not knowing which side to turn to, run from; To survive the Borderlands you must live sin fronteras be a crossroads. —Gloria Anzaldua (1987)     

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.     

Enhancing the Responsiveness of Family-Based CBT Through Culturally Informed Case Conceptualization and Treatment Planning

Family-based CBT has been shown to be effective in controlled settings for an array of youth mental health difficulties, yet disparities in treatment engagement and outcomes across culturally diverse groups remain. In practice, cultural minority families are less likely to reap the demonstrated benefits of supported programs. Although there have been tremendous advances in case conceptualization, leading models have largely ignored cultural factors, contributing to observed disparities. The present paper reviews recent advances in science-informed case conceptualization and highlights how such advances nonetheless have failed to provide guidance on systematically incorporating cultural formulation into assessment and treatment planning. We then build upon Christon et al. (2015) useful 5-stage model of science-based case conceptualization in an effort to move the field toward culturally informed case conceptualization. We highlight how leveraging cultural assessment—such as with the use of the Cultural Formulation Interview (CFI)—can facilitate the incorporation of cultural factors into each of the five stages of science-based case conceptualization. A case example is utilized to illustrate key opportunities for strategically incorporating relevant information gleaned from the CFI into culturally responsive care with youth and families.