Praptomojati, A., Icanervilia, A. V., Nauta, M. H., & Bouman, T. K. (2024). A systematic review of culturally adapted cognitive behavioral therapy (CA-CBT) for anxiety disorders in Southeast Asia. Asian Journal of Psychiatry, (92), Article 103896. https://doi.org/10.1016/j.ajp.2023.103896

Summary by: Marsil Bader

Cognitive Behavioral Therapy (CBT) is a proven effective treatment for many anxiety disorders. However, one of the issues that arise from trying to implement CBT in each culture is that it is deeply rooted in western cultures. This raises questions about whether CBT is equally effective in non-Western cultural contexts without further adaptation. There is a growing recognition in psychological literature that there needs to be a certain effort in trying to make CBT more accessible in other eastern contexts, and cultural adaptation is essential for success in mental health intervention. The following article examines how CBT has been modified in some Southeast Asian populations to fit their cultural norms and values and potentially improve treatment effectiveness; this modification is called CA-CBT (Culturally Adapted Cognitive Behavior Therapy). 

In the following research paper, the researchers systemically reviewed and selected seven different studies that met the inclusion criteria for examining CA-CBT. Studies were included if they examined anxiety based on DSM criteria, utilized any kind of cultural adaptation for CBT, and reported outcomes related to anxiety symptoms. The studies included: One randomized controlled trial, three quasi-experimental studies, and three case reports. These studies were conducted in Thailand, Indonesia, Malaysia, and Singapore. The disorders that are mainly examined in this report are PTSD, social anxiety disorder, panic disorder, and generalized anxiety disorder. 

This article recognizes two different kinds of adaptation frameworks: peripheral adaptation (adaptations that increase treatment acceptability) and core adaptations (adaptations that change the core mechanics of the treatment to better suit the population).  These adaptations varied in depth; only four studies provided clear descriptions of how the adaptation process was conducted. 

Some of the peripheral changes that were conducted include: translating therapeutic materials, adjusting vocabulary to improve cultural relevance, and using cultural examples when talking of exposure exercises. Additionally, one Indonesian study shortened the length of CBT to respond to cultural barriers to longer treatment formats, this was a peripheral change to accommodate cultural expectations.  

In terms of core adaptations, two studies integrated religious or philosophical traditions directly into the CBT model. The study conducted in Thailand incorporated Buddhist meditation and cognitive distancing exercises into their cognitive restructuring. Furthermore, in the Malaysian case study, the researchers integrated Islamic practices, such as prayer, qur’anic referencing, and spiritual coping into the treatment process. These core changes aimed to connect cultural belief systems to the CBT model to enhance their relevance and appeal to the clients.  

Regarding effectiveness, we will examine the only RCT included in this paper. This study demonstrated that CA-CBT produced significantly greater improvements in PTSD symptoms compared to generic counseling. It remains unclear whether CA-CBT is more effective than CBT in these contexts. As the absence of comparison groups limits the strength of conclusion, this is highlighted as an issue in the studies which were picked for this analysis. Furthermore, inconsistent and incomplete reporting of cultural adaptation processes, along with a lack of transparency regarding their rationale, makes it difficult to assess replicability and develop specific guidelines for future cultural adaptations. Due to the limited number of eligible studies, a meta-analysis was not feasible, and the researchers conducted a narrative synthesis instead. 

To conclude, this paper identifies a small and growing body of research on CA-CBT, whether these adaptations involve surface-level modifications or deeper integrations of cultural or religious values. Whether these adaptations happen on a surface level or deeper integrations of cultural or religious values. Evidence suggests that CA-CBT may be acceptable and potentially effective in these specific populations, but more rigorous research must be conducted, and more randomized controlled trials need to be conducted. Future research should focus on adapting a standardized framework with full transparency concerning the cultural adaptation process.