Shared learning database

Southern Health NHS Foundation Trust
Published date:
November 2013

Cognitive behavioural therapy (CBT) is recommended in treatment guidelines for psychotic symptoms (NICE, 2009) but clients from some minority groups have been shown to have higher dropout rates and poorer outcomes. This can present a challenge in implementation. This study assessed the effectiveness of a culturally adapted CBT for psychosis (CaCBTp) in Black British, African Caribbean/Black African and South Asian Muslim participants.

Please note that this example was originally submitted to demonstrate implementation of CG82 Schizophrenia (update). CG82 has now been replaced by CG178. The example has been reviewed and continues to align with the new guidance.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

This study assessed the effectiveness of a culturally adapted CBT for psychosis (CaCBTp) in Black British, African Caribbean/Black African and South Asian Muslim participants. The aim was to:

a) Assess the feasibility of the culturally adapted CBT for psychosis (CaCBTp) with specified BME groups.
b) Further modify CaCBTp in accordance with emerging findings.

Reasons for implementing your project

Cultural influences are reported in the clinical manifestation, prevalence, treatment access and outcomes for individuals with schizophrenia. Cantor-Graae and Selten (2005) meta-analysis of 18 studies demonstrated a significantly increased risk of schizophrenia in migrant groups from developing countries with variation of risk by both host countries and countries of origin. Cognitive Behavioural Therapy (CBT) for schizophrenia is an evidence-based adjunct to medication and recommended internationally (Dixon et al., 2009; NICE, 2009). However, clients from some black and minority ethnic (BME) groups e.g. the African Caribbean and Black African groups have shown higher dropout rates and poorer outcomes compared with the White group (Rathod et al., 2005). This is a major challenge in implementation of the NICE guidelines for minority cultural groups. Cultural adaptation and understanding of ethnic, cultural and religious interpretations remains an underdeveloped area (Rathod et al., 2008). Griner and Smith (2006) have shown an effect size of 0.45 for culturally adapted evidence based interventions in comparison to traditional treatments (Wykes et al., 2008) whilst the meta-analysis by Huey and Polo (2008) was inconclusive. Evidence from small pilot studies suggests that locally adapted CBT with minority populations has been successful (Carter et al., 2003; Kubany et al., 2003; Hinton et al., 2004, 2005; Patel et al., 2007; Rojas et al., 2007; Rahman et al.,2008). Rathod et al. (2010) following a recent qualitative study reported that in principle, culturally adapted CBT for psychosis would be acceptable to BME clients. The recommendations from this study were incorporated into a CBT manual (Kingdon and Turkington, 2005) using Tseng et al.'s (2005) framework of cultural adaptations of psychological therapies. The authors agreed that Tseng's framework would allow fidelity to the core principles of CBT with adequate flexibility for adapting the therapy to cultural beliefs, thereby preserving validity to the original treatment. Use of this framework also allows the various dimensions described by Bernal (1995), namely language, persons, metaphors, content, concepts, goals, methods and context to be considered when adapting the therapy. Hence the Tseng et, al model was suitable as it explores the philosophical orientation, practical considerations and theoretical considerations before technical adjustments.

How did you implement the project

Our adaptions to therapy have been developed using systematic qualitative and quantitative methodology. Based on Lau's and Berrera's recommendations, the adaptation team have used systematic methodology using information from qualitative (Rathod et al., 2010) and quantitative studies (Rathod et al, 2013). These studies, like the previous adaptions, were specific to cultural groups that had shown poor outcomes of an evidence based intervention, CBT for psychosis. The culturally adapted CBT in this work uses a framework proposed by Tseng et al (2005). The framework includes four levels of adjustment to the therapy: 1. Philosophical Reorientation or re-examination and orientation of the fundamental view of life which affects the direction and goal of therapy e.g. acceptance or conquering; normality and maturity. From a philosophical perspective, culture determines an individual's basic view of and attitude toward human beings, society, and the meaning of life, thus will have an obvious impact on the client in his or her search for improvement. When differences in cultural background exist between the client and therapist, there may also be differences in general philosophy and values and therapists need to understand the issues. This includes: a. Level of acculturation b. Beliefs and Attributions of illness c. Cultural orientation towards psychotherapy 2. Practical considerations of societal factors that impact on the performance of therapy e.g. economic conditions, immigration policies, health systems and reputation of local units, funding arrangements, level of stigma associated with mental illness, racism, etc, that impact on the client?s experiences and often determine their trust or lack of it in the system of care. 3. Technical adjustments of methods and skill in providing psychotherapy, including the mode and manner of therapy and various clinical issues within the therapy for clients of various backgrounds. This incorporates an understanding of: a. Setting and environment of therapy b. Therapeutic relationship c. Choice of therapy d. Family structures and goals e. Role of Religion 4. Theoretical Modifications of concepts need to be made for a best fit for the individual and their cultural strength. a. Body and Mind b. Self and ego boundaries c. Individuality and Collectiveness d. Personality development e. Parent child complex f. Defense mechanism and coping

Key findings

A randomised controlled trial was conducted in two centres in the UK (n=35) in participants with a diagnosis of a disorder from the schizophrenia group. CaCBTp participants were offered 16 sessions of CaCBTp (as recommended by NICE 2009) with trained therapists and the Treatment as usual (TAU) arm continued with their standard treatment.

Assessments were conducted at three time points: baseline, post-therapy and at 6 months follow-up, using the Comprehensive Psychopathological Rating Scale (CPRS) and Insight Scale. Outcomes on specific subscales of CPRS were also evaluated. Participants in the treatment arm completed the Patient Experience Questionnaire (PEQ) to measure satisfaction with therapy. Assessors blind to randomisation and treatment allocation conducted administration of outcome measures. In total, n=33 participants were randomly allocated to CaCBTp arm (n=16) and treatment as usual (TAU) arm (n=17) after (n=2) participants were excluded.

The main findings of this study were that culturally adapted CBT for psychosis was acceptable and effective. The CaCBTp group engaged well in therapy as indicated by low attrition rates, mean number of sessions attended and the high scores on the PEQ questionnaire. There was a significant reduction of symptomatology on CPRS total and subscale scores post treatment.

Analysis was based on the principles of intention to treat (ITT). This was further supplemented with secondary sensitivity analyses. Post-treatment, the intervention group showed statistically significant reductions in symptomatology on overall CPRS scores, CaCBTp Mean (SD)=16.23 (10.77), TAU=18.60 (14.84); p=0.047, with a difference in change of 11.31 (95% CI:0. 14 to 22.49); Schizophrenia change: CaCBTp=3.46 (3.37); TAU= 4.78 (5.33) diff 4.62 (95% CI: 0.68 to 9.17); p=0.047 and positive symptoms (delusions; p=0.035, and hallucinations; p=0.056). At 6 months follow-up, MADRAS change=5.6 (95% CI: 2.92 to 7.60); pb0.001. Adjustment was made for age, gender and antipsychotic medication. Overall satisfaction was significantly correlated with the number of sessions attended (r=0.563; p=0.003).

Key learning points

The findings provide evidence for the implementation of NICE guidance through use of psychological interventions for minority populations and a benchmark for culturally adapted CBT for psychosis for BME populations. Low attrition rates in the CaCBTp arm and high levels of satisfaction suggest that this intervention was sensitive to the needs of participants from BME groups. The benefits of this project will be realised at different levels:
1. An effective treatment recommended by NICE and based on cultural explanations will ensure better quality of care for this group of patients due to better engagement and outcomes. Offering CaCBTp offers choice and an evidence based alternative or adjunct to psychotropic medication (DoH:DRE, 2003; Inside Outside: Sashidharan, 2003).
2. Implications for policy makers include the training of staff and dissemination of this therapy within resource constraints. Provision of CBT is a cost effective way of managing patients with psychosis in the community as the relapse rate is found to be low (Turkington et al., 2006a,b).
3. There are implications for further development of clinical or public health practice due to the role of this treatment in early intervention, relapse prevention and effective community care.

Contact details

Dr Shanaya Rathod
Consultant Psychiatrist
Southern Health NHS Foundation Trust

Secondary care
Is the example industry-sponsored in any way?

This trial was part funded by the Delivering race equality (DRE), Clinical Trailblazers programme and Southern Health NHS Foundation Trust.