The CBT Dive

E21 Interview: Culturally adapted CBT and treatment for complex disorders, in-person and online

• Rahim Thawer, MSW • Episode 21

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In this interview, Dr. Farooq Naeem shares his longstanding research interest in CBT and culture. He discusses how CBT concepts can conflict with the beliefs of people in non-Western cultures and then delves into the various ways people can understand and approach depression and schizophrenia from their own worldviews. He also discusses his research on using CBT for psychosis and delivering CBT interventions by e-mail.

GUEST BIO: Farooq Naeem is a Professor of Psychiatry at the University of Toronto and a psychiatrist at the Centre for Addiction & Mental Health. Dr. Naeem pioneered techniques for culturally adapting CBT. These techniques have been used to adapt CBT in South Asia, North Africa, Middle East, Kenya and China. His research areas include CBT, psychosis and culture, with an overall aim to improve access to CBT. He has also published on issues related to health services and quality improvement. He works with a team of IT experts and has developed a CBT-based therapy program called eGuru that can be delivered through web-based and smartphone apps. 
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ABOUT THE CBT DIVE PODCAST
The CBT Dive is a video podcast that brings therapy skills to the real world. Each episode welcomes a new guest who wants to explore a challenging situation using the most common cognitive behavioural therapy tool: the thought record.

ABOUT HOST
Rahim Thawer is a queer, racialized social worker and psychotherapist based in Toronto. He's created The CBT Dive podcast to support folks who want to learn how to use a thought record and to demystify what therapy can look like.

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UNKNOWN:

Thank you.

SPEAKER_00:

Welcome to the CBT Dive, a vodcast that goes into the lives of real people with real struggles. Each episode welcomes a new guest who wants to explore a challenging situation using the most common cognitive behavioral therapy tool, the Thought Record. Your host, Rahim Thawar, is a social worker and psychotherapist based in Toronto and well-known for his work in LGBTQ communities. He's created the CBT Dive to demonstrate What therapy can look like and share intervention skills for wellness. We hope that each episode helps you along on your own journey for insight and self-compassion.

SPEAKER_01:

Hello, welcome to the CBT Dive. Today I have a special guest, Dr. Farouk Naim. I'm just going to say a little bit about our guest before we start asking questions. So Dr. Farouk Naim is a professor of psychiatry at the University of Toronto and a psychiatrist at the Centre for Addiction and Mental Health. He completed a Master's of Science in Research Methods in Health and later a PhD in CBT and Culture from Southampton University in England. He also trained in psychiatry in Liverpool. Farouk pioneered techniques for culturally adapting CBT. These techniques have been used in Thank you so much. Welcome, Dr. Naeem. Thank you so much for being here.

SPEAKER_02:

Thank you. Pleasure.

SPEAKER_01:

Yeah. So, Dr. Naeem, let's start with your PhD topic. It seems like early on in your career, or fairly early on, you knew you were interested in cross-cultural approaches to mental health interventions. What got you interested in that?

SPEAKER_02:

Thank you. I think that's... very important question because it allowed me to share my journey or the beginning of the journey. Please do. You see, I was doing my senior residency training with David Kingdon, who's a pioneer in CBT for psychosis. And I was looking at data from different trials. And one thing I noticed was, and we're talking about like 2003, four. And I realized that even in cities like Manchester and Birmingham, where there's a huge number of non-white people. In these trials, there were not many non-white people. So first of all, I thought, you know, what's going on? So first thing seemed like the level of recruitment. And when we looked at the data a bit closer, we realized that even those who join or are recruited into the trials, They dropped out very quickly. So then I started looking at the literature and I realized that, and actually at that time, there was not a lot of literature. There were some from the US, but nothing in Europe or the global mental health. So I then became familiar with the concept that the The modern therapies which are developed in Western Europe or North America, they are underpinned by different cultural values. And I kind of reflected on it, and I kind of realized, really, that's true, because you see, in CBT, we have a concept of dysfunctional beliefs, right, which I'm sure you're aware of. Yes. One dysfunctional belief, for example, is dependence on others. or sacrificing your need for the needs of others. So these are some of the dysfunctional beliefs in traditional CBT. But they're not dysfunctional beliefs in many non-Western societies. They are actually, you know, you're seen in high esteem if you actually sacrifice your needs for the needs of others. others in many Asian and African and rights cultures. So I thought there's something, there's something missing here. And that's the reason I decided to do my PhD in CBT and culture.

SPEAKER_01:

Okay, lovely. Well, you already started talking about what I wanted to get into, which is, you know, what are some examples of how like Western cultures approaches to therapy or CBT in particular don't always fit with other cultures. I ask this because I think some people would say, you know, therapy altogether is Western and not for other people. But I think you and I would both agree that they can be adapted. But I guess I'm trying to figure out what is it that doesn't fit for people? What needs to change?

SPEAKER_02:

It's not just really the Western therapy. You know, mindfulness is an Eastern spiritual tradition. And I want to make it very clear because especially therapists in the West or people in the West think mindfulness is some kind of psychotherapy that was invented in South Asia, which is not true. But my point is mindfulness was adapted by the Western therapists. So adaptation of therapy is not something new, number one. Number two, even if you look at the CBT model, CBT model has been adapted over the years. So for example, you know, if you look at the history of the CBT model, the initial model by Beck was for depression. Then you saw adaptations for anxiety. Then the CBT model was adapted for trauma. Right? And then CBT for psychosis is also an adaptation of the original model. So adaptation is not something new. And in fact, my take on adaptation is that when it comes to cultural adaptation, you should not change the theoretical or you should not touch the model, but you should... You should modify the method of delivery to engage people from other cultures.

SPEAKER_03:

Okay.

SPEAKER_02:

So you don't change the theory. But anyway, regardless, my point is adaptations of CBT or psychotherapies are not new. And I mean, even if you think about the history of Western psychotherapies, you know, therapies have evolved and have been adapted. So, for example, we started with behavioral therapy, then REBT comes, then it becomes a little bit more refined, becomes CBT, and then it becomes third wave therapies, which have CBT and mindfulness techniques, right? So adaptation is not anything new. new. And in terms of differences between the Eastern and the Western cultures, there are multiple kinds of differences. For example, and I can give you just one or two examples. One example I gave already was dysfunctional beliefs. Another example would be working with the families. The CBT especially the Northern American CBT is very much focused on, and it's been criticized, right? You know that the main criticism of CBT was, okay, it was developed, which I don't agree or disagree in particular, you know, people have the right. But yeah, people say CBT was developed for the Wall Street middle-class white men. Remember, that is the main criticism of CBT. So yes, it is underpinned by individualism, okay? And so what do you do when you're dealing with people who are not individualistic, who live in communities, who live in families, extended families, and the family wants to know what's going on in therapy. And that's something we teach our therapists, you know, to not share any information or not to engage anyone. You see, these are important kind of differences. Finally, just one huge difference is the illness belief model. Now, the causes of illness are biopsychosocial in the Western world. And in many non-Western countries, the causes of mental health problems are spiritual. They have a huge... spiritual component, right? So in other words, the illness, belief, motel, or cause and effect relationship are different. So the formulation that I advise in culturally adapted CBT is a biopsychosocial spiritual formulation rather than a biopsychosocial.

SPEAKER_01:

Okay, thank you for that. Look, as you're speaking, it's really making me think about... my own experience with different cultural formulations of mental health or mental illness. And culturally, you know, my community often would say, would think about nudger, which is like a kind of evil eye, or they would talk about things like gin possession, like a spirit possession. They might also think about mental illness as a result of, you know, not being pious enough. It's like a religious kind of repercussion. Things like that. And so what does it mean to really adapt CBT to make it culturally appropriate when, you know, I think from a certain perspective, some of those beliefs or that ideology of mental illness would be seen as, I don't know, in itself delusional or in itself, you know, like I'm seeing a bit of a A conflict. So help me understand, how do we adapt this model?

SPEAKER_02:

When you say conflict, what do you mean by conflict?

SPEAKER_01:

Well, if I were to say I'm struggling with depression, and I think it's because it's the result of evil eye. I'm the target of someone else's contempt. because I showed too much pride, for example. You know, something like that. You know, one might say, okay, my belief itself is delusional or it's unfounded.

SPEAKER_02:

Yeah. So you see, yeah. I'll just take... one example and elaborate on that. And you did mention that. And that is being religious means you can't be depressed. You touched on that. Now, that's a very common belief among Muslims and Jews. Because it's based in the holy books. But the exact kind of verses are, and I'll just kind of that if you are a true believer, you will not be sad. So you see, my work, because my work took me, and I'll give you another couple of examples in a second. So there were actually time, it took me some time to explore a certain kind of belief, and I'm not going to say pathological or normal or whatever, And I had to explore. So in this case, I had to talk to a lot of religious scholars, both Jewish and the Muslims. And then actually they told me is that the holy books actually talk about you won't be sad in the afterlife. That's very important thing. Yes. Yes. So basically the explanation is, you know, if you are a good believer, it makes sense, right? From religious point of view. But people actually have misinterpreted that as, okay, you're going to be depressed or unhappy in this world too. So a lot of this work is actually helping people or tracing the belief or the origin of the belief and see why. where it's coming from. And that's why a big part I advise of the culturally adapted CBT is to work with people, say spiritual and faith healers, so to understand the spiritual part of the origin of a certain mental health problem that person believes in. And when you present this, excuse me, explanation to many patients, they're absolutely fine. And it makes sense to them. They say, okay, oh, that's what it means. So that is about, that's a very important part. So you see some investigation, working with people from that kind of background who can explain these beliefs to you as a therapist so you can explain to the patient. And there are other examples. For example, in my work, when I compare the differences between, and I'll take this one group, South Asians in England, because most work on South Asians comes from England. Unfortunately, North America does not have a lot of research work on South Asians. I was a bit surprised when I moved to Canada a few years ago to see that even though South Asians are the biggest minority in this country and yet there's not any research on mental health of South Asians or generally health of people of South Asians. Anyway, so one example was when you compare, so we were comparing the results and one thing we noticed like, you know, was biological, psychological, social, and then there was some kind of very cultural kind of beliefs, and it took me some time to explore where they're coming from. For example, one is phlegm, increased phlegm in the body. Okay. can be a cause for mental health problems. So I had to explore, I had to look, and I asked people, and I obviously looked at the literature and everything, and then it turns out, this is actually a Greek concept, old Greek medicine concept. And then I'll tell you where it came from, how did it end up in South Asia, right? The second example is one person, not one, but many people believe that increased heat in the liver can cause mental health problems. So again, it took me some time, and I looked, I explored, and then I found this belief comes from the old Chinese medicine. Heat, cold, different organs. Right, right. Third example, some people said masturbation can cause mental health problems. Then again, I had to explore and I realized that it's actually a belief that comes from Ayurveda, the Indian medicine. So you see, okay and my understanding is because you see like greek medicine in the old time that was the most advanced medicine like the current western medicine is these days right and then plus also especially south asia and uh uh south asia uh you know the there's so many innovators and they all came through there. And when they came, they came with their medicines, with their doctors, right? Old time, I think of the old times. Armies used to travel with the physicians and, you know, it was very slow. So that's where these beliefs, kind of that's how they traveled. So you can see there are some really interesting kind of beliefs when you're dealing with this population. And the way to deal with that is, and obviously you can't change that because if your father's told you that your depression is because of phlegm in your body, then you're less likely to change that view until it presents some solid evidence for you, number one. Number two, the belief is really, really strong and, you know, it's not kind of, but, okay, important thing to keep in mind, people in the non-Western cultures also have multiple component model of mental illness. That's a very important thing. And it's a good thing. Because you see, if somebody is saying, okay, yes, there are biological causes, you know, genetic causes are very common among South Asians and Asians. And it was a bit shocking for me when I realized this for the first time. You know, you might be aware that Many South Asians hide mental health problems in the family because of the impact it can have on arranged marriages. Because the concept of the genetic transmission of disease is actually very strong in these cultures. It is shocking, isn't it? You wouldn't think that, right? Okay. But they will be, they'll have such strong belief in genetics, but yeah. So the whole belief, how hiding, you know, there are multiple causes, obviously. The genetic component is very, very strong. So, so yeah, so it's about modifying the beliefs, providing education, but also because it's multi-component, so you don't necessarily have always need to fight against one belief when you know the person believes that it's a multifactorial kind of position.

SPEAKER_01:

Okay, so if I'm hearing this right, when we think about beliefs about the cause of illness, phlegm, masturbation, these kinds of things, it wouldn't be the clinician's job to change those beliefs necessarily, but just to be aware of that, right?

SPEAKER_02:

Yeah. Yeah. Okay. And you see in many, very often you can educate patients. So it's not like your religious belief is so fixed that they wouldn't change. So, you know, you can always educate them. And, and if you feel that that's kind of, they're not changing, then, you know, then if the person has a, they use biopsychosocial factors. Anyways, you can work on, you can still work with age. That's my point.

SPEAKER_01:

Okay. Here's my question. Have you, so in the research you've done, what have the outcomes been of, in delivering CBT interventions to people in different countries and different cultures. So specifically, I think you've done studies in Pakistan with South Asian Muslims, but feel free to draw on any study. I'm just interested to see what the uptake and outcomes are like. Because when we talk about a North American study, you know, or a study in the UK, we're saying that, you know, there's a high attrition of South Asians or they're not well represented. So when we go to a South Asian context, what does the intervention look like? What are the outcomes?

SPEAKER_02:

Yeah, so the outcomes in general of culturally adapted interventions are better than the standard CBT. Wow. Yeah, yeah. However, this is still a very kind of new field And there are not many RCTs, there are not many fully powered RCTs. So the jury's still out. Okay. Yeah, but the existing evidence actually indicates that people are more, you know, likely to benefit from culturally adaptive CBT. And it makes kind of sense, really, even if you don't think about, you know, because the basic concept in CBT is to provide an individualized therapy, right?

SPEAKER_01:

Right.

UNKNOWN:

Right.

SPEAKER_02:

Even if you don't think about the evidence from the research, it is the duty of every therapist to think about a client's culture. Isn't that right? That's what we teach. That's where we train our therapists.

SPEAKER_01:

Dr. Naeem, I'm really interested in talking a bit further about your work around CBT for schizophrenia and psychosis. I think there's, I know a lot of clinicians who struggle with clients who have psychotic symptoms, have been, you know, are on antipsychotic medication. Some are functioning very well and others bring out a lot of hopelessness in their clinicians. And so I think there's sometimes, This idea that people with schizophrenia are very difficult to treat. Can you tell me a bit about what CBT for psychosis or schizophrenia looks like? And perhaps what's the goal of CBT with people living with schizophrenia?

SPEAKER_02:

Yeah. Thank you. Now, CBT for psychosis is a British kind of adaptation, so it's not as popular in North America as it should be. Most of the RCTs come from Europe. Okay. And the last time I looked, I think more than 40, 50 randomized controlled trials have been conducted, and the evidence overwhelmingly indicates towards the effectiveness of CBT for psychosis in reducing delusions, hallucinations, even negative symptoms. So the overall aim is to help the person to become more aware of the symptoms to help them develop some insight, some self-awareness and reduce the distress. reduce the intensity of the symptoms, and therefore improve the quality of life of patients. The main kind of techniques we use for delusions, we use Socratic dialogue. Right. And for hallucinations, coping skills, but also re-attribution techniques, challenging the voices or teaching patients to challenge the voices. Negative symptoms. For negative symptoms, we use behavioral activation. So all these kind of things are used. But yeah, the overall idea is to reduce distress and improve quality of life. And there's plenty of evidence that it

SPEAKER_01:

was. Okay. So it makes me wonder a bit about like this idea of adaptation and learning more about different cultures, adapting the original model for different kinds of illnesses. Do you adapt the medium of therapy as well? I've read like in some of your work, you've talked about doing CBT interventions by email. Can you tell me a bit about that? How does that work? How do you structure that work?

SPEAKER_02:

So that's really something I realized recently. seven, eight years ago. And it was mainly, you know, by that time, I had conducted a few RCTs. I knew adaptive CBT works. Well, then I actually realized it doesn't matter how much I adapt CBT, the issue is of access. right because right forget about adaptive cbt uh we don't have uh uh cbt therapists or number of sufficient number of therapists to provide therapy to the general population in general so So that's when I became more interested in improving access to therapy. And not just for the refugees or immigrants kind of population, but for everyone. And then another thing, around about the same time I started noticing that internet is very cheap in many low middle income countries. Okay, mobile phones are right. So for$50, you can buy a high quality smartphone in India and Pakistan and Sri Lanka, right? So these kind of countries, you can buy a very cheap mobile. So that's the kind of time I also realized that this is the only kind of way that we can improve access to CBT. I see. So that's why I took that direction. And so eGuru, which was a set of CBT apps, I stopped working on that when I moved to Toronto four years ago. I was in Queens before that for three years. And because I got busy. But now I've started working on eGuru apps again. But also, you see... Recently, actually, we published the very first online culturally adapted CBT. It's a pilot kind of evaluation. And we conducted that. And as a first... culturally adapted online CBT program published from South Asia. And it actually happened yesterday. And we found that- Wow, congratulations. Yes, thank you. And people engage. you know, with therapy and the results were fantastic. So, so, so you see it seems like, and you know, the other thing also we need to keep in mind in global mental health, poor countries are becoming richer. People are becoming more educated. And in addition to have to, to improve access to digital technology. So all these factors are, I mean, you know, we should focus on using apps and web apps to deliver therapy. So that was the whole idea behind it.

SPEAKER_01:

All right. That's very interesting. Are there any populations or conditions for which CBT should not be conducted electronically, like by email or by using an app? So,

SPEAKER_02:

Manay, I don't know the exact kind of answer to your question because there's not a lot of research in this area. This is a very new area. However, the exclusion criteria most randomized controlled trials have used are kind of straightforward. So, for example, having accidental Technology is number one. Number two is digital literacy. Digital literacy is very important. And third is not having any intellectual disability, right? I see. So these are the very basic kind of requirements for digital mental health or delivery of CBT through digital technology.

SPEAKER_01:

Now, you have this particular interest in doing CBT for psychosis, and I just wonder, would that be appropriate to do by email? I worry that people with psychosis sometimes may have a tough time using technology to be vulnerable.

SPEAKER_02:

Not necessarily. It depends on the stage. of illness depends on the age of the patients. Many people actually, you see, one thing we need to keep in mind is modern medication has helped a lot. You know, we have this concept that people, and it's true, it's true. Until 10, 15 years ago, a lot of patients used to have cognitive deficits, which is part of the normal kind of illness, process, so chronic schizophrenia and cognitive deficits, you know, they grew together. And it still happens, unfortunately. With the modern medication, improved compliance, I see that it's becoming less and less of a problem. So while we still struggle, and while we still have a reasonable number of patients who are treatment-resistant, The important thing to keep in mind is that the majority of our patients, they actually can engage. Having said that, I think that there are one or two trials cbt online cbt but that's actually face to face through zoom or webex for schizophrenia and and also some kind of websites with mixed results but generally this has not been used a lot in people's schizophrenia One area where some progress has been made is use of virtual reality programs to reduce fear and phobias in general, but also in people with

SPEAKER_01:

schizophrenia. Oh, that's fascinating. The virtual reality programming. Okay. Well, we've been talking a bit about schizophrenia, and I want to ask... what your stance has been on that diagnostic label in the clinical and academic community. I think there's been some debate on whether or not it's a helpful label, whether the stigma makes it, I don't know, whether the stigma itself is too much of a barrier. So I wonder, what is your stance? Should it be renamed? What's its utility?

SPEAKER_02:

Yes, no, I actually, when, you know, I was actually very, very much in favor of changing the name of schizophrenia. And I and my group, we wrote some letters and articles as well 15 years ago. But you see, then I actually, I don't think it's going to make any change if you change the name.

SPEAKER_03:

Uh-huh.

SPEAKER_02:

And the reason is because I learn and because of my work, actually I started thinking more about the cultural sort of factors and it gave me, you see, it gave me multiple insights working in many low middle income countries. So for example, I learned that People believe that epilepsy was because of evil spirits.

SPEAKER_01:

Huh, okay.

SPEAKER_02:

In many, many, many low middle income countries, especially the Middle Eastern and the South Asian. I don't know about other cultures. Okay. And you see what happened then. So this is like 30 years ago, 40 years ago, people tell me, my colleagues in the field. And then they say, as the anti-epileptics became available and people could afford the medication and it became obvious that epilepsy can be treated with the help of medication, now hardly anyone believes that this is because of evil spirits. Right? For me, it was a big lesson. The reason it was a big lesson was because it showed you can't change people's minds or their concepts or their misconceptions about an illness. And this, I think, also includes stigma, to be honest with you, until and unless you change the outcome. I mean, if you look at the history of mental health problem, wasn't there a time when people with dyslexia were burned in Europe because people thought they are witches, right? So it's not really that changing a name is going to make any difference. And even just psychoeducation alone is not going to make a difference. I now believe that until we change the outcome of schizophrenia, I don't think just changing the name is going to make

SPEAKER_01:

a difference. Okay. To that end, do you think, and we're getting towards the end, so I hope I'm not tiring you

SPEAKER_03:

out.

UNKNOWN:

Okay.

SPEAKER_01:

I've heard some people argue that what we call symptoms of psychosis can be explained better through other cultural lenses. And so shouldn't be in the category of psychosis. So for example, you know, after a loved one dies, lots of people report that they will get, like that loved one will show show up in their dream, you know, and somebody would be inclined to call that a visit and they would see it as something affirming. But if we stick to a certain kind of model, we might call that, we might say that it's normative, but we might also call it a kind of psychosis. And I wonder how, if that language could be challenged a bit. What are your thoughts on that?

SPEAKER_02:

I think any clinician who does that is a terrible condition. I'm serious. I've seen this happening. Yeah. I've seen this happening, people being diagnosed with schizophrenia because they had a trauma, they see things at night, in the dark, et cetera, et cetera, or other kind of visions. you know, and being diagnosed or someone who hears the kind of voice of a dead relative or things like that. So to somebody who, a clinician who diagnoses this kind of picture, you see, schizophrenia should, people should be careful with diagnosing

SPEAKER_03:

schizophrenia

SPEAKER_02:

because you are giving someone a lifelong label. Right. And we need to be careful with this kind of experiences which are mainly expressions of distress. I mean, you can even talk about the religious or spiritual experiences people see or hear things, you know, religious experiences. But the distinction between schizophrenia and this kind of experiences is that of duration, and then the exclusion and most importantly, it's also about being careful in judging the symptom. You know, for schizophrenia diagnosis of schizophrenia, we first have to think about the duration, right? Symptoms should be there. Number two is you know, the collection of symptoms. So generally we have, and this is like every disorder in reason five. Number three is exclusion. That person shouldn't be using, you know, drugs, alcohol, stimulants, that kind of stuff. My point is many psychiatrists, unfortunately, do not think about these things general criteria when they diagnose someone. And the biggest example is I see so many patients, you know, being misdiagnosed with bipolar. And when I actually asked them, they say they had mood swings, but the mood swing was never more than a day or two. Now, in order to diagnose bipolar, the person should have experienced manic episode for at least one week, right? So my point is, I think that's more a kind of problem misdiagnosis because the Merton DSM ICD-11 systems are freely kind of advanced. And if psychiatrists use them carefully, they shouldn't be misdiagnosing people. But the simple answer is that's a terrible thing, you know, if it's happening even in this day and

SPEAKER_01:

age.

UNKNOWN:

Yes.

SPEAKER_01:

Dr. Naim, my last question, if clinicians want to get training in being not just culturally competent, but being able to deliver culturally adapted CBT for specific communities and populations, how might they get that training?

SPEAKER_02:

Yeah. So, In Canada, I'm currently leading a large randomized controlled trial. And it was actually a mixed study, but currently we are on the RCT phase.

SPEAKER_03:

And

SPEAKER_02:

we are running the trial in Vancouver, Toronto, and Ottawa. And at the end of this RCT phase, we'll develop a training specifically for the trial is for South Asians there. And we'll develop the training package and that will be available freely. So just. Look out for that.

SPEAKER_03:

Yes.

SPEAKER_02:

Yes.

SPEAKER_01:

Okay. Lovely. Thank you so much, Dr. Naim for. My pleasure. For being with us. And when I'm back in Toronto, maybe our paths will cross again.

SPEAKER_02:

Absolutely. Lovely. You take care. It was a pleasure talking with you. Thank you. Bye.

UNKNOWN:

Bye.

SPEAKER_00:

Thanks for tuning in to the CBT Dive. Don't miss an episode. Subscribe to our YouTube channel at thecbtdive.ca. You can also listen on the go wherever you get your podcasts. To follow Rahim on social media, check out ladyativan.com. See you soon.

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Rahim Thawer, MSW

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