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ScienceDirectCognitive and Behavioral Practice 21 (2014) 139-144

Commentarywww.elsevier.com/locate/cabp

Parameters for Creating Culturally Sensitive CBT: Implementing CBT inGlobal Settings

Devon E. Hinton, Massachusetts General Hospital and Harvard Medical School and Arbour Counseling ServicesBaland Jalal, UC–San Diego

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

M URRAY et al.’s (2014–this issue) study suggests thatthe transdiagnostic CBT they have developed may

be effective as implemented in low- and middle-incomecountries. They refer to the treatment as a “CommonElements Treatment Approach” (CETA), and they state itcan be given by lay counselors. It is a modular treatment.As the authors indicate, several research groups havedeveloped transdiagnostic protocols (e.g., Barlow et al.,2010; Norton, 2008). The researchers describe theirversion of transdiagnostic CBT and discuss how trainingwas conducted and some aspects of the treatment. In thisopen pilot study, the treatment seemed feasible and wellaccepted.

Inspired by this study and other recent studies (e.g., Basset al., 2013) that show thepotential efficacy of CBT in globalcontexts, this commentary suggests ways to make the nextwave of CBT treatments in global contexts sensitive tocultural context. A recent article advocated for a checklist tobe used for all studies published in journals to assure their

ords: global health; CBT; culture; implementation; scale up;sment; transdiagnostic treatment; culture; treatment adapta-global health; PTSD

-7229/12/139-144$1.00/014 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.

cultural sensitivity (Lewis-Fernández et al., 2013). Here wesuggest a kind of checklist that could be used to evaluate thecultural sensitivity of a CBT intervention in a global context.These parameters have guided our treatment developmentand the global health research agenda more generally(Hinton et al., 2005; Hinton, Hofmann, Pollack, & Otto,2009; Hinton, Hofmann, Rivera, Otto, & Pollack, 2011;Hinton et al., 2004; Hinton, Rivera, Hofmann, Barlow, &Otto, 2012; La Roche, 2012; Patel, 2012; van Ginnekenet al., 2013).

Parameters to Evaluate the Cultural Sensitivity of aCBT Intervention in Global Contexts

Identify the Cultural Group

The particular cultural groups ideally should beidentified. For example, many Burmese are Karen andother hill tribe members, a culturally separate group fromthe majority of Burmese. Often identity is nested—forexample, a Tamil speaker in Hindi-speaking India. Or aperson identified as Iraqi could belong to an Arabic,Kurdish, Turkmenian, or Assyrian cultural group, andcould be Muslim (Sunni, Shia, Alevi), Yezidi, Zoroastrian,Christian, or Jewish. This is important because it will havean impact on many of the parameters below, such as agroup’s history of trauma, stigma in the group aboutmental illness, catastrophic cognitions about symptoms,and religious-based techniques that may be included intreatment.

140 Hinton & Jalal

Specify the Language of the Group and Languageof Treatment

It is important to indicate the languages the partici-pants speak and whether the treatment was conducted inthe preferred or a secondary language. For example, inmany countries there are multiple languages spoken but asingle national language, with variable fluency in thenational language: in Iraq, while Arabic is the nationallanguage, in major parts of Northern Iraq Arabic is notspoken, but rather Kurdish and Turkman. Degree offluency of the client in the language in which therapy wasconducted needs to be described. Developing treatmentstailored to the specific regional culture and regionallinguistic dialects is essential to enhance client engage-ment and communicate lessons in terms of daily lifeexperiences.

Identify Key Demographic Variables

The treatment population should be characterized interms of key demographic variables such as economicstatus, education, and literacy level. For example, the levelof education and literacy will affect the ability to givewritten handouts. It is also important to know thesevariables so as to evaluate generalizability of a particularintervention.

Detail the Religious Background of the Group

One should characterize the group in question inrespect to religious background. Is the group mainlyBuddhist, Christian, Muslim, or another religion, and whatis the distribution in the group? Which type of Buddhism(e.g., Theravandan or Zen), Christianity (e.g., Pentecostalor Catholic), or Islam (e.g., Shia or Sunni)? Whenconducting a treatment, religious or spiritual beliefsmay provide sources of resilience or particular obstaclesto care. The local religion may provide ways to frametreatment to make it more acceptable. For example,Murray et al. (2014–this issue) made sure to matchtherapist and client in respect to gender at the Iraqi siteto adapt treatment to religious beliefs.

Identify Typical Traumas in the Group

It is crucially important to identify the traumas that agroup being treated typically experiences. It may be thatthe group in question endured mass violence of somekind, may be fleeing from a genocide or civil war, andmayhave high rates of sexual violence. When providingeducation about CBT, these traumas can be specificallydescribed and addressed. Identifying traumas is alsocrucially important from a public health standpoint: itmay be found that sexual violence or domestic violenceis endemic in a certain context. This has important

implications in respect to treatment and public healthinterventions: the therapist should be careful to specifi-cally query about a history of the trauma such as domesticviolence, should be sensitized to its possible presence, andshould be aware of what local resources are available forsomeone so impacted.

Identify and Address Key Stressors

It has been shown that worry may be a key generator ofdistress in traumatized populations and other populations(Hinton & Lewis-Fernández, 2011; Hinton, Nickerson, &Bryant, 2011). From a public health standpoint, whenapplying CBT in global contexts, it is important to beaware of local problems that may be addressed for theentire group: security concerns, refugee status, access towater, and so on (Hinton & Good, in press). Ideally thestressors may be addressed at the community level as animportant public health intervention. Also, one shouldspecify whether the participant sees someone who canhelp address key practical problems, such as theequivalent of a social worker. The CBT may need toaddress practical problems as part of treatment, a kind ofbehavioral activation and didactics in coping (Nezu,Nezu, & Lombardo, 2004).

Describe How and Where the Patient Was Identifiedand Recruited in the Health Care System

It is critically important to specify how patients wererecruited, such as from community samples, a primarycare setting, or other locations. This gives insight into thenature of the health care system and gives informationabout the generalizability to other contexts.

Identify Key DSM Disorders

In certain groups like traumatized refugees, one of thegroups in this study, certain disorders like PTSD andpanic disorder may be particularly elevated (Hinton &Lewis-Fernández, 2011). Each group may have a uniqueprofile of DSM disorders; for example, among Cambodi-an refugees, other than PTSD, there are extremely highrates of panic attacks and panic disorder. The profile ofdisorder will inform treatment and the design andimplementation of modules. For example, if PTSD iscommon in a locality, then this should influenceassessment and the usually given modules. Murray et al.(2014–this issue) indicate that in the Iraqi group all hadPTSD and depression, while in the Burmese group, 68%PTSD, 37.5% depression.

Identify Key Psychopathological Dimensions

Other than DSM disorders, it is important to identifykey psychopathological dimensions in a group, such as

141Commentary: Parameters for Creating Culturally Sensitive CBT

pathological worry (rather than “GAD”), catastrophiccognitions, or panic attacks (Hinton, Nickerson, et al.,2011; Morris & Cuthbert, 2012). This is in keeping withthe call for dimensional analysis and impacts on themodules that will be provided in treatment.

Identify the Exact Somatic Complaints of Concern

It has been found that somatic symptoms are promi-nent in many non-Western populations (Hinton & Good,2009; Hinton & Lewis-Fernández, 2011). Ideally oneshould identify key somatic concerns in a population sothat these may be addressed in CBT. This can beconsidered as the assessment of a psychopathologicaldimension, namely, somatic complaints, but with the aimof assessing key somatic complaints, in order to avoid an“abstraction error,” meaning only considering somaticsymptoms in general without assessing key symptoms ofconcern. Not assessing key somatic symptoms is also anexample of “category truncation” (Hinton & Good, inpress; Hinton & Lewis-Fernández) in respect to assessinglocal distress, and so too is not assessing other keyconcerns such as catastrophic cognitions.

Create Models of How Disorder Is Generated in thePopulation in Question to Identify Treatment Targets

For a population, the way that particular complaintscome to be generated should be identified. We have donethis to explain the high rates of somatic complaints andpanic attacks among Cambodian refugees, showing, forexample, triggers of somatic arousal such as worry orstanding up from the sitting or lying position and the keyrole of catastrophic cognitions about and trauma associ-ations to those sensations (Hinton & Good, 2009; Hinton,Hofmann, Pitman, Pollack, & Barlow, 2008; Hinton,Nickerson, et al., 2011; Hinton, Pich, Marques, Nickerson,& Pollack, 2010).

Identify and Address Key Catastrophic Cognitions

A standard part of CBT is addressing catastrophiccognitions about symptoms such as about PTSD symp-toms and somatic symptoms (Hinton & Good, in press;Hinton, Rivera, et al., 2012). For example, manyCambodian refugees fear that neck soreness indicatesthat the neck vessels will burst, and they fear that dizzinesson standing indicates the onset of a dangerous khyâlattack, or “wind attack,” a surge of khyâl and blood upwardin the body that may cause various disasters (Hinton et al.,2010). Or many Cambodians think that worry willoverheat the brain and cause permanent forgetfulness.Learning the local ethnopsychology, ethnophysiology,and ethnospirituality as it applies to symptoms andprocesses like “worry” is a key way of identifying thesecatastrophic cognitions. In every culture, there will be

local ideas about how symptoms of anxiety and depressionare generated and treated. More generally, we havesuggested that all outcome studies in cross-culturalsettings should include a list of locally salient somaticcomplaints, catastrophic cognitions, and cultural syn-dromes not assessed in standard measures, what we havecalled “Symptom and Syndrome Inventories,” for exam-ple, a “Cambodian Symptom and Syndrome Inventory,”or C-SSI (Hinton, Hinton, Eng, & Choung, 2012; Hinton,Kredlow, Pich, Bui, & Hofmann, 2013).

Making CBT Techniques Tolerable and Credible for theCultural Group

Exposure for trauma may be particularly problematic.It has been found that conducting exposure amongethnic populations presents challenges and may lead todropout and worsening (Hinton, 2012). Even withWestern populations, in treatments conducted by adoctoral-level therapist, this approach has been consid-ered problematic (Hinton, 2012). A phase approach hasbeen suggested, among other methods, to increaseexposure tolerability. Murray et al. (2014–this issue)employ analogies to make exposure more tolerable:configuring imaginal exposure as cleaning a wound. InIraq, using a more culturally specific metaphor, theauthors framed exposure in a way that creates positiveexpectancy: the fear women have of making bread on anopen fire, a fear that diminishes over time. The authorsalso mentioned metaphors that were used that are notculturally specific but rather grounded in daily life tomake treatment more acceptable: configuring learningthe cognitive triangle as a “spoonful of treatment,” owingto the local popularity of taking medication for ills.

Identify Issues of Therapist–Client Matching

In particular, this is important in respect to gender. Asthe authors describe, in the Iraqi context the therapistshould be of the same gender.

Identify and Address Complaints of Most Concern toThose Being Treated

In a cultural context, certain symptoms will be of greatconcern: among many Cambodian refugees, sleep paral-ysis, dizziness, poor sleep, and panic attacks (Hinton et al.,2013). Of note, the key local complaints may be culturalsyndromes. For example, Cambodians frequently attri-bute anxiety symptoms to “heart weakness” and “windattacks” (khyâl attacks), and these attributions producemultiple catastrophic cognitions. As described below,framing treatment as addressing these key complaintsgreatly increases CBT acceptability and adherence. Asdescribed above, failure to assess and treat key concerns

142 Hinton & Jalal

such as somatic symptoms and cultural syndromes wouldbe a case of “category truncation.”

Identify and Address Complaints of Most Concern tothe Community

One should ask local leaders about which behavioraland symptomatic issues are of key concern, askingspecifically about violence, substance abuse, and suicid-ality in the community. If the treatment is then framed asaddressing these issues, it will reduce stigma about theailment and mobilize the community.

Utilize Local Sources of Resilience and Recovery

In certain localities, there may be healing traditionssuch as Buddhist meditation or Sufism that are helpful topatients (Hinton & Kirmayer, 2013). These techniquescan inform the CBT treatment itself and its components,and participants may be encouraged to use such methods:for Buddhists, incorporating meditation into the treat-ment may be useful, and for an Iraqi Islamic population,incorporating a type of supplication known as Dhikr whereGod’s name is repeatedly recited. In fact, there are a widevariety of spiritual healing techniques that are common tothe major Islamic denominations and sects (e.g., Sunnis,Shias, or Alevis, as found in Iraq): Ruqyah, in whichspecific verses are recited from the Quran, traditionallythought to promote health, is compatible with CBT.Ideally, treatment intervention can be framed in terms ofthese local traditions. In some cases, it is useful to end theCBT treatment with local rituals that indicate purificationor healing in a general sense, which helps to changeself-image and creates a sense of positive expectancy(Hinton, Rivera, et al., 2012). As an example of this, for anIraqi Islamic population, there is Wudhu and Ghusl(ritualistic washing of face, arms, and feet or the entirebody), which are types of spiritual purification techniquessignifying a transition from spiritual impurity to purity. Inaccordance with this perspective, Murray et al. (2014–thisissue) mention that Buddhist meditation was sometimesincluded for the Burmese speakers.

Address Stigma About the Disorder and GettingTreatment for the Disorder

One should determine how various psychologicaldisorders are viewed in the treatment locality. As muchas possible the disorder should be normalized. This helpsto reduce self-stigma and stigmatization by others. It maybe necessary to educate family members. Videos ofpatients and community leaders in which they talkabout the disorder and the importance of treatmentmay help. It may be necessary to frame the treatment asaddressing locally salient concerns that are not stigmatiz-ing, like poor sleep, nightmare, or somatic complaints. It

may be that coming to the location of treatment isstigmatizing. This may lead to the need to do thetreatment in a primary care or other nonstigmatizinglocality. Stigmatization was mentioned by Murray et al.(2014–this issue) with respect to the site in Thailand,where local participants considered treatment to be onlyfor the “crazy” or psychotic; consequently, the interven-tion was called a “program” and not a “treatment.” Inaddition, for both sites, Murray et al. used an engagementmodule in which family members were sometimesincluded.

Address Structural Barriers to Treatment

These include transportation issues, payment issues,and ability to take time off to go to the clinic.

Attend to Social Demand Characteristics and EconomicIncentives

In a culture context, social demand and financialaspects of the study may influence results both at the levelof the therapist and patient: participants may feelpressure to report positive outcome. The social desirabil-ity issue is discussed by Murray et al. (2014–this issue).

Increase Credibility and Positive Expectancy

This will be achieved by various means such as statingthat treatment will help with symptoms of greatestconcern, like poor appetite or key local somatic com-plaints and cultural syndromes. Showing videos of thosewho have gotten better through the treatment may helpimprove credibility/expectancy, or so too videos of localleaders who advocate treatment and attest to its efficacy.Credibility/expectancy may be enhanced by framing thetreatment as incorporating local therapeutic techniqueslike meditation in a Buddhist context and Dhikr in an IraqiIslamic context. Credibility and positive expectancy willarise from the credibility and positive expectancy of keyCBT techniques, which was described above. Murray et al.used certain metaphors to increase positive expectancyand credibility about certain techniques: in Iraq, Murrayet al. tried to increase positive expectancy in part bydescribing the treatment as a “prestigious program.”Credibility and expectancy can be built by certaindescriptions of the entire treatment, and about specificelements. For example, in our treatment, we compare thetreatment to the making of a special local dish thatinvolves multiple culinary steps in order to promotepositive expectancy and to teach patience about the timeframe of improvement. Murray et al. included an initialmodule, “Encouraging Participation,” which aimed topromote engagement.

143Commentary: Parameters for Creating Culturally Sensitive CBT

Maximize Adherence

Whatever increases credibility and expectancy willtend to increase adherence. Also, adherence, in thesense of dropping out or missing sessions, will relate tovarious other issues like stigma about treatment andstructural barriers (e.g., lack of transportation or inabilityto take time off from a busy work schedule). A person mayattend sessions but not actually do homework or otherpotentially helpful aspects of a treatment, anotherexample of nonadherence. Metaphors that emphasizethe need to complete all parts of the treatment, like thosein which all elements of the treatment are analogized toall the steps needed to prepare a dish that is highly prizedin the culture, may help to increase adherence, andadherence will be increased by anything that decreasesstigma, helps to increase credibility/expectancy, ortolerability, or addresses structural barriers.

Specify Scale-Up and Sustainability Potential

Scale-up and sustainability will be greatly influenced bythe level of education required of the service provider,how much time is needed to be trained, whether thetreatment can be taught to multiple providers, how manysessions the treatment entails, whether the treatment isgroup or individual, and whether it allows task shifting.And the scale-up and sustainability potential will beinfluenced by public health system variables: by whetherthere is a place in the health care system to situate thetreatment, whether the government is willing to incorpo-rate the CBT into standard treatment, and whether thereis funding available for the program.

Conclusion

Murray et al.’s (2014–this issue) and other recentstudies (e.g., Bass et al., 2013) show the potential of CBTin global contexts. Based on our work, we have attemptedto outline some key ways of implementing CBT in globalcontexts to make it culturally sensitive so as to maximizeefficacy and effectiveness. Ideally, in studies involvingimplementation of CBT in global contexts, the parame-ters outlined in this article would be accepted as standardsfor treatment implementation in global contexts.

The type of information detailed above can begathered in various ways. It may be through a review ofthe literature, discussion with community leaders, ethno-graphic surveys, and pilot studies in a population. Also,the treatment itself may involve asking participants aboutthese domains. For example, in our treatment (Hinton,Rivera, et al., 2012), we specifically ask participantswhether they are using any other means to cope withdistress, such as local religiously informed techniques,and we use probes to elicit local catastrophic cognitionsand key somatic complaints.

To conclude, Murray et al. (2014–this issue) should belauded for undertaking this ambitious project, and devel-oping this new treatment package. In addition, the studygives opportunity to reflect on some key aspects of culturallysensitive CBT as seen in global context, at a key time ofreflection given that such studies are increasingly beingconducted in an attempt to address global disparities inhealth care, part of a crucially important research agenda.

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Address correspondence to Devon E. Hinton, M.D., Ph.D., ArbourCounseling Services, 10 Bridge Street, The Simpson Block, Lowell, MA01852; e-mail address: devon_hinton@hms.harvard.edu.

Received: December 21 2013Accepted: January 1 2014Available online 15 February 2014