Taking care of our mental health is essential, no matter where we are in the world. In the more Western parts of the world, psychological interventions, such as Cognitive Behavioural Therapy (CBT), are effective in treating a wide range of common mental health problems (e.g., depression, anxiety, post-traumatic stress disorder, etc.). However, the effectiveness of CBT as applied in other areas of the world is much less discussed. Fortunately, there is some evidence from high–quality studies (e.g., systematic reviews, clinical trials) suggesting that CBT is linked to favourable mental health outcomes compared to other treatments in diverse contexts.

Cultural Adaptations in CBT

What is culturally adapting a treatment? It can be defined as modifying an evidence-based treatment to consider the patient‘s cultural context. Interestingly, CBT can be adapted to different cultural contexts. Several systematic reviews suggest that CBT’s effect on mental disorders is actually stronger when the treatment is adapted to local cultural contexts. Further, cultural adaptions for treatment can take many forms relevant to the local culture. For instance, questionnaires have been translated to local languages and then tested to ensure fidelity to the original scale; more time can be taken to explain the techniques, processes, and aims of CBT. Additionally, culturally appropriate stories and metaphors have been integrated into the delivery of the CBT. In order to continue adapting CBT to more cultural contexts, it is of primordial importance to develop a better understanding of how mental disorders are experienced and expressed in various ways by the patient.

CBT delivery in low-and middle-income countries

Although CBT can be flexible to context, there are obstacles to CBT intervention delivery in low- and middle-income countries (LMIC) where resource deprivation (such as fewer mental health professionals available to deliver treatment) is disproportional. This is problematic given that unique sociocultural factors in LMICs contribute to the increasing prevalence of mental health problems. Fortunately, it has been found that local nurses, volunteers, university students, social workers, and students can be trained as lay counselors to effectively deliver CBT.

There is global evidence supporting the effectiveness of culturally adapted CBT among LMICs. For instance, two systematic reviews reported similar findings of results suggesting that psychological interventions, including CBT, significantly improved outcomes in a range of common mental disorders (e.g., depression, schizophrenia) among LMICs, including regions such as East Asia and Pacific, Eastern Europe and Central Asia, Latin America and the Caribbean, Sub-Saharan Africa, North Africa, and the Middle East (Patel et al., 2007; Singla et al., 2017). Similar results have been reported in Sri Lanka and rural Pakistan. Short-term sessions of CBT led to reduced symptoms of medically unexplained symptoms and increased patient satisfaction (Sumathipala et al., 2000) and improvements in depression (Rahman et al., 2008). A more recent systematic review assessing current evidence of trauma-focused CBT (TF-CBT) in low-resource community settings in East or Central Africa found that TF-CBT effectively treated trauma-related symptoms and improved psychosocial functioning in both children and adolescents (Thomas et al., 2020).

Cultural experiences and expressions of psychological problems

Cultural diversity around the globe may lead to assumptions that treatments developed in one region of the world may not be effective when implemented in other regions. Given the vast diversity and influence of one’s culture, it is also often assumed that psychological problems are uniquely experienced depending on one’s cultural environment. However, evidence from global research suggests that there are more similarities than differences in how psychological problems are experienced throughout the world. Although psychological problems are expressed in various different ways, often depending on the context, the symptoms of distress share common features. The effectiveness of CBT has been rigorously examined in Western regions of the globe; however, research findings point toward CBT as perhaps the only evidence-based psychological intervention that can be adapted to diverse cultural contexts to improve mental health outcomes around the world.

Author: Sasha Gunpat, M.A
Graduate Student in Clinical Psychology

References:
Patel, V., Araya, R., Chatterjee, S., Chisholm, D., Cohen, A., De Silva, M., … & Van Ommeren, M. (2007). Treatment and prevention of mental disorders in low-income and middle-income countries. The Lancet, 370(9591), 991-1005.

Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F. (2008). Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. The Lancet, 372(9642), 902-909.

Singla, D. R., Kohrt, B. A., Murray, L. K., Anand, A., Chorpita, B. F., & Patel, V. (2017). Psychological treatments for the world: lessons from low-and middle-income countries. Annual review of clinical psychology, 13, 149-181.

Sumathipala, A., Hewege, S., Hanwella, R., & Mann, A. H. (2000). Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka. Psychological medicine, 30(4), 747-757.

Thomas, F. C., Puente‐Duran, S., Mutschler, C., & Monson, C. M. (2020). Trauma‐focused cognitive behavioral therapy for children and youth in low and middle‐income countries: A systematic
review. Child and Adolescent Mental Health.