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.

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.

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.

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 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.

Lesbian, gay, bisexual, queer and other sexual minority (LGBQ+) people experience higher levels of psychological difficulties than heterosexual people. Evidence suggests that LGBQ+ treatment outcomes within England’s Improving Access to Psychological Therapies (IAPT) services are worse than the outcomes for heterosexuals, especially for bisexual people and sexual minority women. IAPT services provide evidence-based treatments like cognitive behavioural therapy (CBT), typically for anxiety or depression. This study explored LGBQ+ adults’ experiences with IAPT services and/or primary care counselling. LGBQ+ adults (n = 136) answered an online questionnaire (fixed-response and optional open-ended questions) about their access and treatment experiences. Descriptive statistics summarized multiple-choice responses. Qualitative data were analysed through thematic analysis. Before access, 41.9% of participants were concerned about experiencing LGBQ+ stigma/discrimination within psychological services. Only 13.2% of participants thought their sexuality negatively impacted their treatment, although prejudice/discrimination may be underestimated as 33.6% participants did not disclose their sexuality to practitioners and sexuality was not discussed in treatment for 44.0% of participants. Bisexual clients were significantly less likely to disclose their sexuality. The barriers LGBQ+ people described within IAPT or primary care services included: feared or experienced stigma in the services; reluctance to disclose sexuality; inconsistent discussion of sexuality in treatment; a lack of awareness and understanding towards LGBQ+ identities and community-specific challenges; and distrust, disillusionment and exclusion resultantly. Overall, 52.2% thought services could be improved for LGBQ+ individuals. This study identified multiple issues to be addressed in therapist training and service development.

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.

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.