Britain has increasingly become a multi-cultural society. In order to improve access to primary care psychological therapy including cognitive behavioural therapy (CBT), there has been an increase in focus on cultural adaptation and cultural responsiveness. To date, these adaptations have focused on domains such as language, beliefs and values. In this case, familism was the focus for adaptation. The client was a 22-year-old female from a black African-British background. She presented with severe symptoms of chronic depression as measured on routine standard questionnaires and the interview. She had minimal success from previous interventions and was struggling to make progress. Therapy was guided by the client’s views on what issues had a bearing on her difficulties. The client hypothesised that familism factors with themes around ‘my parents’ culture’ and ‘family comes first’ were interacting with her cognitive behavioural factors to maintain her problem. She requested the involvement of her family in her treatment plan. In line with the Improving Access to Psychological Therapies–Black, Asian and Minority Ethnic service user Positive Practice Guide, this was integrated as part of her formulation. Upon involvement of her father in a single session, the client attained reliable improvement. She attributed her improvement to this involvement. By the end of therapy, she reached recovery, which was maintained at 3-month follow-up. This study was responsive to the client’s own perceived cultural needs through the integration of familism into her CBT formulation. It illustrates a client-led cultural adaptation of CBT to treat chronic depression.

Cognitive behavioural therapy (CBT) is generally defined as a short-term, problem-oriented psychotherapy that focuses on modifying dysfunctional emotions, thoughts and actions. In clinical practice, CBT consists of a number of cognitive and behavioural techniques that aim to help patients suffering from psychological disorders. The practice of CBT is well established in Western countries. In non-Western countries, CBT is still in the process of being established as the evidence-based psychotherapy. Despite being the heart of the Arab world, the development and practice of psychotherapy in Egypt in general, and CBT specifically, is still emerging. The training and practice of CBT has received a mixed response in Egypt. In practical settings, evidence-based CBT is subject to individual and cultural variations and adaptations. Many local studies examining the efficacy of CBT in psychiatric disorders among different population groups in Egypt have been conducted. Unfortunately, many of these studies have not been published and therefore have missed the opportunity for international recognition. The current review aims to explore the practice of CBT with a specific focus on national research of efficacy and adaptability of CBT for different populations in Egypt.

This study explores the mental health difficulties associated with severe trauma as experienced by refugees and asylum seekers, and issues related to psychological treatments. An evaluation was conducted of a culturally adapted cognitive therapy group programme for Tamil refugees and asylum seekers in the Wandsworth IAPT (Improving Access to Psychological Therapies) service. Data were examined from 16 Tamil participants who accessed the service between 2014 and 2015 and subsequently engaged in the group programme between 2015 and 2016. The IAPT minimum data set (PHQ9, GAD-7, Phobia scale and WSAS) and IES-R (Impact of Events Scale Revised) were used as quantitative measures. Qualitative feedback about the programme was also obtained. A positive change in the wellbeing of participants was indicated by a reduction in the severity of negative symptoms for all metrics and qualitative feedback provided additional evidence that participants had benefited from the programme. The implications of these findings are discussed.

Western values influence cognitive behavioural therapy (CBT) as it was primarily developed and practised in the West. As understanding the cultural context has been linked to better therapy outcomes, it has been suggested that CBT might need modification to non-Western clients’ cultural backgrounds. Previously we developed a cost-effective approach to adapt CBT for clients in China and Pakistan. In this study, we applied the same methodology for local clients suffering from depression and anxiety in the Kingdom of Saudi Arabia and Bahrain. This study aimed to understand the views of patients with depression and anxiety, caregivers and mental health professionals about CBT to develop guidelines for culturally adapting CBT for depression and anxiety. We conducted semi-structured interviews with the patients (n = 42), caregivers (n = 11), and psychiatrists and psychologists (n = 16). The data were analysed using a thematic framework analysis by identifying emerging themes and categories. The themes emerging from the analyses of interviews by each interviewer were compared and contrasted with those of other interviewers. The results highlighted barriers of access to and strengths of CBT while working with these patient groups. Patients and their caregivers in both countries use a bio-psycho-spiritual-social model of illness and seek help from multiple sources. Therapists emphasized the need for using local idioms, culturally appropriate translation and minor adjustments in therapy. There were no thematic differences between the two sites. These findings will be used to culturally adapt a CBT manual, which will be tested in a randomized controlled trial.

Cognitive behavioural therapy (CBT) in its current form might not be acceptable to service users from a variety of backgrounds. Therefore, it makes sense to adapt CBT when working with diverse populations. Contributors to this special issue of the Cognitive Behaviour Therapist have tackled the issues around the cultural adaptation of CBT from various perspectives, using a variety of methods, and have addressed topics ranging from cultural adaptation to improving access to CBT. Here, I briefly summarize and discuss the papers in this special issue. I start with a systematic review of CBT for social anxiety across cultures. Seven articles cover aspects of adaptation of therapies for people from different backgrounds. Three papers discuss the issues of gender and sexuality when using CBT, while another three papers focus on refugees, asylum seekers and the homeless, and two papers describe the application of CBT with religious populations. Finally, there are seven papers on issues related to service delivery, practice and training and supervision when working with a diverse population. Collectively, papers in this special issue provide us with sufficient evidence that cultural considerations play a vital role when using CBT, offer practical suggestions for improving cultural competence and most importantly, can catalyse future research. However, the full potential of culturally adapted interventions will not be realized until and unless access to CBT is improved. Therefore, there is a need to build robust evidence to convince funders, policy makers and service managers.

Conversations around improving access to psychological therapies for BAME (Black, Asian and minority ethnic) service users have been ongoing for many years without any conclusion or resolution. BAME service users are often under-represented in primary care mental health services, and often have worse outcomes, leading to them being portrayed as ‘hard to reach’, and to deterioration in their mental health. They are over-represented in secondary care mental health services. The authors of this article argue that more resources are required in order to understand the barriers to accessing mental health services, and improve both access and recovery for BAME service users. This paper examines concepts such as race, ethnicity and culture. It aims to support service managers and therapists to develop their confidence to address these issues in order to deliver culturally competent psychological therapies to service users from BAME communities, with a focus on primary care. It is based on our experiences of working with BAME communities and the feedback from our training events on developing cultural competence for CBT therapists. The paper also discusses the current political climate and the impact it may have on service users and the need for therapists to take the wider political context into consideration when working with BAME service users. Finally, the paper stresses the importance of addressing structural inequalities at a service level, and developing stronger ethical guidelines in the area of working with diversity for CBT therapists in the UK.

This article describes a clinical protocol for supporting those presenting with post-traumatic stress disorder (PTSD) and dissociative symptoms, particularly dissociative flashbacks, based on a cross-culturally applicable model. The protocol is discussed from the perspective of working with a refugee and asylum seeker population, although many of the principles will be applicable to clients from any background presenting with these dissociative symptoms. The protocol addresses the assessment and formulation of a client’s dissociative symptoms. It includes guidance on sharing psycho-education with clients regarding the evolutionary function of dissociation and developing practical strategies to monitor and manage dissociative symptoms. The strengths and limitations of this protocol are also discussed.

Cognitive behaviour therapy (CBT) in an effective technique used widely in Western countries. However, there is limited evidence as to the utility, perception and understanding of CBT in developing countries. This study describes and investigates the experience of CBT training and practice in a group of practitioners in Tanzania. A qualitative approach to the investigation was used, and seven participants from Tanzania’s only psychiatric hospital who had completed CBT training were interviewed. The resulting verbatim transcripts were analysed via interpretative phenomenological analysis. Five superordinate themes emerged from the analysis: ‘the medical model’, ‘novelty’, ‘practicalities’, ‘process’ and ‘therapist effects’. The two themes ‘therapist effects’ and ‘process’ are discussed in detail as these may be particularly relevant to the clinical application of the therapy in a new culture and context. The implications for future development of CBT in Tanzania are considered. In developing CBT for dissemination in Tanzania, specific cultural and clinical issues highlighted by indigenous clinicians need consideration.

Inequalities in mental health treatment access and outcomes for minority ethnic and religious groups in the UK have been recognized for more than a decade; however, work to address these at an operational level is still emerging. In recognition of the need for culturally adapted therapies, researchers at the University of Leeds developed and piloted an adapted therapy for Muslim clients, based on behavioural activation (BA), an existing evidence-based psychosocial treatment for depression. Therapists and supervisors at Touchstone, Leeds have been trained to deliver the culturally adapted approach, which supports Muslim clients who choose to use ‘positive religious coping’ as a resource for health. This paper describes the key elements of the intervention and how it is being delivered in practice to increase service uptake and recovery in Muslim communities.

Cognitive behaviour therapy (CBT) as a treatment for schizophrenia and psychotic-related disorders has been shown to have significantly greater drop-out rates in clients of black and minority ethnic (BME) groups. This has resulted in poor outcomes in treatments. Our recent qualitative study thus aimed to develop culturally sensitive CBT for BME clients. The study consisted of individual in-depth 1:1 interviews with patients with a diagnosis of schizophrenia, schizo-affective, delusional disorders or psychosis (n = 15) and focus groups with lay members (n = 52), CBT therapists (n = 22) and mental health practitioners (n = 25) on a data set of 114 participants. Several themes emerged relating to therapist awareness on culturally derived behaviours, beliefs and attitudes that can influence client response and participation in therapy. The current paper aims to explore one of these themes in greater detail, i.e. client-initiated therapist self-disclosure (TSD). Using thematic analysis, the paper highlights key elements of TSD and how this could impact on therapist’s reactions towards TSD, the therapeutic alliance and ultimately, the outcomes of therapy. The findings appear to show that TSD has significant relevance in psychological practice today. Some BME client groups appear to test therapists through initiating TSD. It is not the content of TSD they are testing per se, but how the therapist responds. Consequently, this requires therapists’ cognisance and sensitive responses in a manner that will nurture trust and promote rapport. Further investigation in this area is suggested with a recommendation for guidelines to be created for clinicians and training.

There has been a large increase in the migration of Muslim populations towards the western world and the USA in the past decade. Many have migrated in the hope of finding a safe home away from war, persecution, or a better economic situation, with many coming from Afghanistan and Syria. Gender and sexual minorities (GSM), or individuals who are not heterosexual and do not identify with their sex assigned at birth, are disproportionately over-represented within migrating groups. While most of these individuals will not have received psychotherapy in their home countries, it is likely they would receive or be required to obtain psychological services as part of the asylum process or through psychoeducational services as a requirement to receive assistance. In exploring the specific needs of Muslim GSM individuals, we highlight the diverse impacts of minority stress, shame, and how these might be mitigated through the integration of acceptance and commitment therapy (ACT) and compassion-focused therapy (CFT). ACT and CFT may provide a helpful framework for a culturally adapted therapy that targets the needs of those experiencing intersectional Muslim and GSM identities, and can foster the cultivation of a meaningful life that can include all aspects of their identities.

There is a very high prevalence of post-traumatic stress disorder (PTSD) within refugee populations and survivors of torture. Refugees, asylum seekers and survivors of torture who access IAPT (Improving Access to Psychological Therapies) can present with unique clinical challenges for cognitive behavioural therapy (CBT) therapists. The use of reflective practice can be beneficial particularly when there is added complexity in the client's clinical presentation. The aim of this paper is to provide an overview of how reflective practice can improve clinical work with this patient group and to identify some of the challenges that refugees, asylum seekers and survivors of torture may present with during therapy. The paper sets out how the use of the critical incident analysis model and clinical supervision can assist to develop reflective practice skills and improve the clinical practice of IAPT CBT therapists who work with diverse populations.

Homeless girls suffer labour and sexual exploitation, abuse, discrimination and social exclusion at a higher rate than the rest of the population. However, worldwide information on homeless girls and intervention programmes for this group are scarce. This study examined the preliminary efficacy of a brief cognitive behavioural group therapy tailored to Mexican homeless girls. The intervention targeted subjective well-being and these determinants: symptoms of anxiety, symptoms of depression, assertive behaviours and functional emotion regulation skills. Results revealed statistically significant differences in symptoms of anxiety and depression, assertiveness, emotion regulation strategies and subjective well-being with treatment effects that ranged from moderate to large. Symptoms of anxiety and depression, and dysfunctional emotion regulation strategies decreased. Assertive skills, functional emotion regulation strategies, and subjective well-being increased. Outcomes were clinically relevant. At 2-month follow-up, participants showed improvement from pre-treatment on all measures. The current study provides unique findings in terms of a promising preliminary intervention that helps restore homeless girls to a healthier social/emotional developmental path especially in the context of Latin American cities. As a result, the clinical implications of this research highlight the urgent need to design effective interventions based on the observed characteristics and identified needs among homeless girls.

Recently there have been a number of developments in cognitive behaviour therapy (CBT) that have led to cultural adaptations of specific interventions and a greater awareness of how in general CBT might be adapted for Black and Minority Ethnic (BME) service users. These developments, however, involve change at the level of the individual therapist and particular treatment approach, but involve very few considerations of what needs to happen at the levels of teams or services in order to best meet the mental health needs of British South Asian and other BME populations. This paper summarizes the way that services need to understand how minority populations use services and how to involve those populations in developing services in order to ensure their needs are best met.

This paper is clinical practice-based, and examines the Greek cultural linguistic schema of Politeness Plural in the application of the Schema Therapy mode model. The philosophical principles of Schema Therapy and the importance the model ascribes on creating a warm therapist–client relationship as a pre-requisite for schema healing are discussed. We further explore the need for the therapist to be culturally sensitive to the linguistic use of Politeness Plural in Greek-speaking populations. We are looking into the reasons of why, whilst culturally sensitive, a schema therapist needs to remain inquisitive of potential maladaptive and/or internalized dysfunctional coping mechanisms of inter-relating that are masked by the use of the Politeness Plural linguistic schema. The implications the cultural linguistic schema of Politeness Plural can have in the therapy outcome are considered. Specifically, we argue that holding on to the Politeness Plural cultural linguistic schema may reinforce emotional distancing and compromise schema healing. The authors identify the need for more research to further understand the issues that are raised in this article. Although the focus of the article is on Greek populations, the matters under consideration may be valuable to other cultures.

The use of transdiagnostic mental health treatments in low resource settings has been proposed as a possible aid in scaling up mental health services. Modular, multi-problem transdiagnostic treatments can be used to treat a range of mental health problems and are designed to handle comorbidity. Two randomized controlled trials have been completed on one treatment – the Common Elements Treatment Approach, or CETA – delivered by lay counsellors in Iraq and Thailand. This paper utilizes data from two clinical trials to explore the delivery of CETA by lay providers, examining fidelity and flexibility of element use. Data were collected at every therapy session. Clients completed a short symptom assessment and providers described the clinical elements delivered during sessions. Analyses included descriptive statistics of delivery including selection and sequencing of treatment elements, and the variance in element dose, clustering at the counsellor level, using multi-level models. Results indicate that lay providers in low resource settings (with supervision) demonstrated fidelity to the recommended CETA elements, order and dose, and occasionally added in elements and flexed dosage based on client presentation (i.e. flexibility). This modular approach did not result in significantly longer treatment duration. Our analysis suggests that lay providers were able to learn decision-making processes of CETA based on client presentation and adjust treatment as needed with supervision. As modular multi-problem transdiagnostic treatments continue to be explored in low resource settings, research should continue to focus on ‘unpacking’ lay counsellor delivery of these interventions, decision-making processes, and the level of supervision required.

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. Most psychotherapeutic interventions have been developed in the West and are underpinned by the values that might be specific only to Western culture. To adapt CBT, we need to understand whether the concepts associated with CBT may conflict with cultural beliefs, identifying barriers to the success of the therapy using the views of experts by experience, public and practitioners. This paper discusses the process, foci and framework of cultural adaptation of CBT. We describe an evidence-based framework for adapting CBT for individuals from non-Western cultures that will benefit clinicians who practise CBT and individuals from different cultural backgrounds.

There is a national drive to increase access to psychological therapies across England, with a specific focus on under-represented groups such as Black, Asian Minority and Ethnic (BAME) groups. Although prevalence rates for common mental health conditions such as depression and anxiety in Orthodox British Jews are less than those of the generic population in the United Kingdom, accessing services to help treat these conditions within this group are considerably less than other groups. This paper seeks to consider reasons for this, as well as what adaptations, both from a therapist and service perspective, can be made to increase access within the Orthodox Jewish community with lessons to be made to other BAME groups.

Vaginismus in one of the most frequent causes of non-consummation of marriage, and of infertility, in Arab-Muslim societies. Cognitive behavioural therapy (CBT) proved to be effective, but it is important to consider the cultural context of the patient attending CBT for vaginismus. The aim of our study was therefore to draw attention to the belief systems and behaviours linked to female sexuality and couple relationship in the Arab-Muslim culture. We present a series of four patients representative of the local culture and show how treatment strategies were adapted to fit these behaviours and belief systems, as well as environmental factors. We found that excessive closeness of family members, allowing the family to be intrusive and exercising pressure on the couple, a strict education which highly values virginity, transmits fear of ‘the male’ and fear of sex, and which links sex with pain, were the common denominator of all patients of our case series. We adapted the classical CBT strategies for vaginismus to our cultural context. The educational component was enlarged. Cognitive techniques were used to modify specific traditional beliefs. The integration of the family, and not only of the partner, into the treatment process proved uniquely beneficial for the patients.