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An evidence-based framework for cultural
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Original Paper
An evidence-based framework for cultural adaptation of
Cognitive Behaviour Therapy:
Process, methodology and foci of adaptation
Farooq Naeem, Peter Phiri, Amina Nasar, Ashley
Gerada, Tariq Munshi, Muhammad Ayub,
Shanaya Rathod
Abstract. Currently there is no evidence-based framework for culturally adapting CBT for clients from the Non-
Western cultural background. We adapted CBT for black and ethnic minority communities in the UK and local
population in Pakistan. This paper describes the framework that evolved from this work, with a focus on the process
of adaptation, details of methods used and the areas that need to be focused in order to culturally adapt CBT in a given
culture. As far as we are aware this is the first adaptation framework that is evidence based and has been tested through
field testing. A series of mixed method studies were conducted in Pakistan and the UK. Adaptation process starts with
(a) background information gathering (b) in-depth interviews and focus groups with the stake holders; i.e., patients,
carers, community leaders and health professionals (c) development of guidelines (d) cultural adaptation of therapy
material, and (e) field testing adapted therapy. Through an iterative process we developed semi structured interviews
that can be used now in low resource settings. The cultural adaptation of CBT should focus on three fundamental
areas; (1) awareness of relevant cultural issues and preparation for therapy, (2) assessment and engagement, and; (3)
adjustments in therapy. The adapted CBT was found to be effective in RCTs. Recently; the above methodology was
used to culturally adapt CBT in China, Middle East and Morocco.
Keywords: Cognitive Behavioral Therapy (CBT), culturally adapting CBT, framework, Non-Western cultures.
WCPRR 2016, Vol. 11, No 1/2: 61-70 © 2016 WACP
ISSN: 1932-6270
BACKGROUND AND INTRODUCTION
Cognitive Behaviour Therapy and Culture.
Cognitive Behavioral Therapy (CBT) has a strong evidence base and is recommended by the National
Institute of Health and Care Excellence (NICE) in the UK and by the American Psychiatric Association
(APA) in the US, for a variety of emotional and mental health problems. However, it has been suggested
that CBT is underpinned by the Western cultural values (Scorzelli & Reinke-Scorzelli, 1994, Hays &
Iwamasa, 2006), and that for it to be effective among patients from Non-Western cultures, it should be
_________________
Farooq Naeem: Queens University, Kingston, Ontario, Canada; Addiction and Mental Health Services - Kingston, Frontenac,
Lennox and Addington, Kingston, Ontario, Canada. Peter Phiri: Southern Health NHS Foundation Trust, Hampshire,
England; Services Institute of Medical Sciences, Lahore, Pakistan. Amina Nasar: Services Institute of Medical Sciences, Lahore,
Pakistan. Ashley Gerada: Addiction and Mental Health Services-Kingston Frontenac Lennox. Tariq Munshi: Queens
University, Kingston, Ontario, Canada; Addiction and Mental Health Services-Kingston Frontenac Lennox. Muhammad Ayub:
Queens University, Kingston, Ontario, Canada. Shanaya Rathod: Southern Health NHS Foundation Trust, Hampshire,
England; Southampton University, Southampton, England.
Correspondence to: Professor Farooq Naeem, Queens University, Ontario, Kingston, Canada. Address: 385 Princess Street,
Kingston, Ontario, Canada.
mailto: farooqnaeem@yahoo.com
NAEEM, F.
PHIRI, P.
ET AL.
culturally adapted (Rathod & Kingdon, 2009). At the roots of these suggestions, it has been said that
Western are different from Eastern cultures in a number of the so-called core values such as Individualism-
Communalism, Cognitivism-Emotionalism, Free will-Determinism and Materialism-Spiritualism
(Laungani, 2004).
Therapists working with ethnic minority clients in the US have developed guidelines for adaptation of
psychotherapies in different settings (Bernal, Bonilla, & Bellido, 1995; Hwang, 2006; Hwang, Wood, Lin,
& Cheung, 2006; Tseng, 2004). Most of these guidelines describe therapists’ experiences of working with
Chinese or Latino clients, and address broad clinical and therapeutic issues. Furthermore, the existing
guidelines did not directly result from research addressing cultural issues. In general, the literature on
guidance of this kind for cognitive therapists is limited (Hays & Iwamasa, 2006).
AN EVIDENCE-BASED FRAMEWORK FOR CULTURALLY ADAPTING
CBT
Currently, no adaptation framework of the kind described above has been developed using a robust
methodology or tested through Randomised Controlled Trials (RCTs). This has been the objective of oue
previous work on the development of culturally adapted CBT for psychosis in Black and Minority Ethnic
(BME) communities in the UK (vgr., Black British, African-Caribbean, Black African and Pakistani and
Bangladeshi), and for depression and psychosis in Pakistan. Currently, this framework is being used in
Morocco, the Middle East region and China.
A series of qualitative studies substantiated by the ethnographic approach were conducted. Culturally
sensitive CBT thus developed was tested in small feasibility studies, and found to be effective. In the initial
phases of our Pakistani project, clinical psychologists (n=5) were interviewed about their experiences of
providing therapy, in particular CBT, to depressed patents (Naeem, Gobbi, Ayub, Kingdon et al., 2010).
Depressed patients themselves (n=9) were also interviewed, focusing on presenting symptoms, referral
procedures, attribution styles, the acceptability of talking therapies, and obstacles in their delivery (Naeem
et al., 2010, 2014, 2015). Focus groups were also conducted with University students (n=34) to find out
the extent to which CBT was consistent with their personal, religious, family, social and cultural values
(Farooq Naeem, Gobbi, Ayub, & Kingdon, 2009). The study group further utilised their help in the
selection of culturally equivalent terminology used in CBT. Information gathered from these preparatory
qualitative studies, as well as the first author’s (FN) own field observations and experience were collated
to develop a framework that guided the CBT adaptation process (F. Naeem, Ayub, Gobbi, & Kingdon,
2009). Preliminary evaluation of the adapted CBT found it to be effective in local settings (Farooq Naeem,
Waheed, Gobbi, Ayub, & Kingdon, 2011). This methodology was replicated to adapt CBT for psychosis
(semi-structured interviews with 33 patients, 30 caretakers and 29 mental health professionals) in Pakistan
(Naeem et al., 2014).
In the UK project, a similar methodology was undertaken with specific ethnic groups (namely, Black
British, African-Caribbean, Black African and Pakistani and Bangladesh) in two sites (Hampshire and
West London). In-depth, face to face, semi-structured interviews and focus group interviews were
conducted with psychotic patients (n=15), lay members from the respective communities (n=52), CBT
therapists (n=22), and experienced health professionals working with service users from these groups
(n=25) (Rathod, Kingdon, Phiri, & Gobbi, 2010). Findings from this study have resulted in a manual of
adapted CBT (Rathod et al. 2015). In a randomised trial to test the acceptability and feasibility of culturally
adapted CBT for post treatment psychosis, the intervention group showed statistically significant
reductions in overall symptomatology on CPRS scores (p=0.047) with some gains maintained at six months
follow-up (Rathod, Phiri, Harris, Underwood, Thagadur, Padmanabi & Kingdon, 2013).
The guidelines developed from the above-mentioned works were also used to deliver and test adapted
therapies through a number of trials in a variety of settings (for example, primary and secondary care) for
various problems (i.e., depression, psychosis and selfharm) (Habib, Dawood, Kingdon, & Naeem, 2014;
Husain et al., 2013, 2014; Naeem et al., 2011, 2014, 2015, 2016). These trials confirmed the effectiveness
of culturally adapted CBT.
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CULTURAL ADAPTATION OF COGNITIVE BEHAVIOUR THERAPY
PROCESS OF ADAPTATION
The process of adaptation of CBT starts with gathering information from the different stakeholders, using
a qualitative methodology. This information is then analysed to develop guidelines that can be used to
deliver a culturally adapted CBT. The therapy material is then translated and included in a manual and
field tested again to allow further adjustments and refinements.
In short, the steps of this process comprise the following sequence:
Stage 1: Review of previous literature and discussions with field experts, ultimately aimed at
gathering information, through the use of qualitative methods, from patients and
caretakers/lay persons, therapists/mental health practitioners and service managers
concerning their experiences and views about a particular problem.
Stage 2: Guidance and specific norms to adapt the CBT manual
Stage 3: Translation and adaptation of therapy material into a manual
Stage 4: Field testing the adapted CBT manual and further refinement of the guidelines
Figure 1 Process of adaptation
Information gathering
Information gathering
Producing guidelines for adaptation
Translation and adaptation of therapy material
Field testing the adapted therapy
METHODOLOGY: HOW TO ADAPT CBT
Both qualitative and quantitative methods are used in this phase. During the qualitative stage, semi-
structured interviews are used to gather information that can be used for the development of more or
less precise guidelines for adaptation. The following areas are typically explored in interviews and focus
groups (1) philosophical and cultural orientation of the patient, including his/her beliefs about a given
illness, its causes and the treatment, especially non-medical treatments including the patient’s experience
of any non-pharmacological help received; (2) an understanding of caretakers’ views about the problem,
its causes and treatment, as well as their beliefs about help-seeking and any non-pharmacological
treatment; (3) the experience of health professionals, including therapists, who help patients carrying the
given problem, and identify barriers they have to overcome in helping these patients. Questions were
asked to further identify techniques the helpers believed were in need of modifications, as well as those
which they found useful; (4) further information gathered from expert therapists, spiritual and religious
leaders and community elders. (The semi-structured interviews evolved from open-ended questions and
focus groups in our initial work can be requested from the first author). The data thus obtained is
analysed using a thematic content analysis and question analysis. A name-the-title technique (Naeem et
al., 2009) is used to find equivalent terminology, rather than using literal translations. A feasibility study
is conducted to determine whether the adapted therapy is acceptable. Finally, a larger RCT is conducted
to determine the therapy’s effectiveness.
World Cultural Psychiatry Research Review 2016, 11 (1/2): 61-70
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PHIRI, P.
ET AL.
FOCI OF CBT’S CULTURAL ADAPTATION
Our experience suggests that in the process of modifying a given therapy to adapt it to a different culture,
it is not only adaptation per se that is essential, but also factors such as access to therapy, its delivery and,
most importantly, its availability. Only a brief outline is provided here, as details have been published
elsewhere (e.g. Rathod et al. 2015). Cultural adaptation of CBT should focus on the following levels:
(i) Philosophical orientation
(ii) Practical considerations of societal and health system-related factors
(iii) Technical adjustments of methods and skills and
(iv) Theoretical or conceptual changes.
Figure 2 The foci of adaptation
Philosophical Technical Practical Theoretical
orientation adjustements considerations modifications
Access and delivery of therapy Cultural adaptation of therapy
Adjustments in Assessment
therapy and
engagement Awareness and preparation
Capacity and Cognitions Culture and
circum- and beliefs related
stances issues
To effectively adapt CBT in a given culture, the following areas of cultural competence (The Triple-A
Principle) must be covered; (1 ) Awareness of relevant cultural issues and preparation for therapy; (2)
Assessment and engagement (3) Adjustments in therapy techniques (“technical adjustments”).
Awareness of relevant cultural issues, in turn, involves (a) Issues related to culture and religion, (b)
Consideration of the capacity and additional circumstances or characteristics of the health system, and
(c) Philosophical orientation including knowledge and beliefs related to health, illness and its
management. There are wider political issues that some may consider go beyond the scope of cultural
adaption; for example, whether therapists from a Caucasian background accept the need for adaptation
of a certain therapy orientation, and what are their beliefs towards a particular cultural group, potential
receiver of the treatment.
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CULTURAL ADAPTATION OF COGNITIVE BEHAVIOUR THERAPY
Table1. An evidence-based framework for adaptation of CBT: The foci of adaptation
World Cultural Psychiatry Research Review 2016, 11 (1/2): 61-70
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PHIRI, P.
ET AL.
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CULTURAL ADAPTATION OF COGNITIVE BEHAVIOUR THERAPY
Culture, religion and spirituality remain as important components of peoples’ lives, and therefore require
full attention and exploration in this context. These factors influence belief systems, especially those
related to health, well-being, illness and help-seeking in times of distress. Culture and religion influence
the cause-effect relationship. For example, the cause of a mishap might be described as “evil eye” or even
“God’s will”. People are also likely to use religious coping strategies, when dealing with distress (Bhugra,
World Cultural Psychiatry Research Review 2016, 11 (1/2): 61-70
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PHIRI, P.
ET AL.
Bhui and Rosemarie, 1999). On the other hand, culture, religion and spirituality may give rise to myths
and stigmas associated with mental illness. Clients from many Non-Western cultures use a bio-psycho-
socio-cultural-spiritual model of disease –thus, not limited to just the psychological nature of mental health
problems. It may be crucial for therapists to acknowledge that their clients will attend therapy as well as
use their traditional help-seeking pathways. Actually, involving faith healers, religious leaders or
community elders might help.
There is also a need to consider the language used in therapy. Language needs to be adapted and, in that
sense, literal translations do not work. We have used the name-the-title technique in our work. Similarly,
the involvement of family members or caretakers needs to be studied. It offers both, possibilities and
problems. Professionals and others involved in adaptation tasks should assess family participation and
consider both the pros and cons, common stressors, guilt and stigma of mental illness in the household.
Interviews with the stakeholders are also likely to offer insights into common barriers related to personal
issues, for example, gender, socio-economic or other problems. A major part of ”traditional” CBT,
involves reading or writing the informational material for various homework assignments. This needs to
be sensitively assessed so that alternative methods can be used, e.g., audio tapes and audio diaries, beads,
counters or symbols for diary-writing.
A detailed discussion should focus on system needs. These are really important in terms of access to and
delivery of therapy. For example, existing health and immigration policies, the number of therapists,
training programs and training needs. Service structure and needs, system organization including referral
modalities might have significant implications in terms of access to therapy. Similarly, clients’ knowledge
of and their beliefs about the health system, treatment providers, available treatments and their likely
outcomes, are important factors in service utilization and engagement. Questions must be asked in
particular about psychotherapy. The pathways to care and help-seeking behaviours have to do with factors
related to social and health systems, cultural and religious beliefs.
Dysfunctional beliefs and cognitive errors may vary from culture to culture (Padesky & Greenberger,
1995). There is at least some research evidence to suggest that this might be the case (Sahin & Sahin, 1992;
Tam et al., 2007). Beliefs related to dependence on others, need to please people around, need to submit
to demands of loved ones, and sacrificing one’s needs for the sake of family are relatively common in
different population. These will assist therapists in achieving what might be culturally appropriate rather
than strictly pursuing the aims of therapy linked to the Western world’s culture.
Structured assessment tools can be used to assess patients beyond the routinely used ones. We have
highlighted the importance of beliefs about illness and its treatment, and this can be evaluated with the
help of the Short Explanatory Model Interview (SEMI) (Lloyd et al., 1998). This interview explores the
client’s cultural background, nature of the presenting problem, help-seeking behaviour, interaction with
physician/healer, and beliefs related to mental illness. The Asian Cultural Identity Schedule (Bhugra,
Bhui, Rosemarie, 1999) is, for example, an instrument used to assess cultural identity and adjustment of
patients in the host culture, assisting the therapist in the adjustment of therapy to the client’s level of
acculturation. This scale describes key concepts of cultural identity such as religion, attitudes toward the
family, leisure activities, rites of passages, food and language. However, this is a lengthy instrument, ao
therapists should familiarise themselves with the instrument, and use some of the questions that they
consider relevant to their work. Other commonly used assessment instruments can be used such as the
Dysfunctional Attitude Scale (DAS) (Weissman & Beck, 1978) useful to evaluate dysfunctional beliefs,
and, in case of doubt, usable with family members or other in the community to see whether some of the
supposedly dysfunctional beliefs are acceptable within this community.
Engagement and therapeutic alliance has been described as a difficulty when providing therapy to different
cultural groups (Rathod et al, 2005). Competence then involves not only clinical competence but also an
understanding of the patient’s culture and religion. In addition to exploring barriers in delivering therapy,
barriers in engagement should be studied. Information regarding patient-therapist relationship can be
easily gathered and can help improve engagement. Involvement of caretakers and relatives usually proves
vital in this regard and should be explored.
In our experience, only minor adjustments in CBT are required. However, some notable similarities exist
across non-Western cultures. Clients from SAM find it difficult to recognise thoughts & emotions. Clients
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CULTURAL ADAPTATION OF COGNITIVE BEHAVIOUR THERAPY
found meditation and mindfulness exercise particularly helpful to help them acknowledge their thoughts
and emotions. The focus of therapists is normally physical symptoms and behaviours at the start. Clients
find behavioural techniques (Behavioural activation, experiments, etc.) and problem solving, particularly
easy to use. Socratic dialogue and downward arrow techniques are particularly difficult to use in this group.
Clients feel uncomfortable if the Socratic dialogue is used without sufficient preparation; the experienced
healers from this cultural background use stories and images to convey their message, and understanding
idioms of distress might help. Finally, structural changes might be required in the provision of therapy,
and this should be explored depending on the organisation of the system and distance from the treatment
facility. These include time, duration, number and gaps between therapy sessions. These authors have
described the detailed findings from their studies elsewhere (Naeem, Phiri, et al., 2015).
PRACTICAL APPLICATIONS OF THE FRAMEWORK: FURTHER
BARRIERS AND PITFALLS
Additional factors might need careful consideration. For example, it will be presumptuous to believe that
everyone from a given culture is the same or has identical characteristics. There must be flexibility in
applying the culturally adapted therapy. Similarly, migrants from a certain background while sharing some
commonalities with the culture of origin, might have wide variations. Racial tensions, experiences related
to migration and political and social systems in the host culture should be taken into consideration. There
might be wide variations between the first and second generation clients. An assessment of acculturation
might help. It might also be helpful to start with cultural adaptation of a focused problem and using a
manualized form of therapy.
CONCLUSION
This paper highlights the process, methods and foci of cultural adaptation of CBT. As far as we are aware
this is the first evidence-based framework for adapting CBT for clients from the Non-Western Cultures.
Adaptation of CBT can be accomplished through a series of steps that involve the various stakeholders.
The process of adaptation should focus on both theoretical and philosophical considerations as well as on
practical issues in improving access to therapy, and in adjusting therapy techniques for the need of local
population.
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