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In 2015, with the beginning of the so-called “refugee crisis,” psychotherapists were facing a large number of severely traumatized and stressed persons in need of treatment. In response, we quickly founded a counseling center for refugees at the Goethe University in Frankfurt. In attempting to implement standard CBT for addressing trauma-related concerns, our efforts were derailed by cultural barriers and other clinical challenges. To address these challenges, we developed a culturally adapted CBT (CA CBT) protocol designed to address the unique needs of ethnic minorities or cultural groups. CA CBT can be delivered as a group intervention, using psychoeducation, meditation, and stretching exercises. The principal focus of the treatment model is to increase resilience and enhance skills for tolerating and overcoming past and current sources of distress. Initial adaptions for the Afghan culture included the presentation of material in the language of the country of origin (i.e., oral and written instructions in Farsi and/or Dari), use of cultural concepts of distress (e.g., idioms of distress such as “thinking a lot”), and culturally appropriate imagery. 

Focus groups with male and female Afghan refugees conducted before the pilot trial revealed that gender-homogenous therapy groups were preferred. As such, the current study only included male participants to ensure a safe, comfortable environment and to minimize trigger potential. Following the pilot trial, participants expressed the need for more help coping with psychosocial stressors and solving problems. In response, problem management was added as a component of the program. 

Each session started with psychoeducation on symptoms of distress and strategies to improve mental health. According to the transdiagnostic approach, several symptom groups were addressed, including depression, vivid memories, sleep disturbances, anger, fear, and somatic complaints. Each session included yoga and stretching exercises, which the therapist demonstrated and participants practiced during the group session. This was followed by problem-solving training, which focused on individual problems and engaged the group in brainstorming solutions. At the end of each session, meditation techniques were taught, including mindfulness breathing and loving–kindness meditation, as well as culturally appropriate guided imagery (e.g., “Persian garden”); these techniques aimed to enhance an accepting attitude toward negative affect and increase positive affect toward the self and others.

Further cultural/contextual adaptations included: 

  • Idioms of distress: “Gham” (sadness), “jigar khun” (expression often used to describe grief or extreme distress; word-by-word translation “liver blood”), “ziad fekr kardan” (thinking too much)
  • Consideration of social or post migration stressors via problem solving training 
  • Modification of loving kindness (in contrast to the original protocol: Due to past experiences stronger focus on benevolence and compassion for oneself, family members, and friends
  • Replacement of the metaphor of the “inner child” (trauma memory) by an “inner alarm system”, to avoid conflict with male gender roles rooted in Afghan culture

We evaluated CA CBT in a randomized controlled design with 24 participants in total. We observed a general reduction in psychopathological distress, depressive symptoms, somatic symptoms and an increase in quality of life. Furthermore, the dropout rate was very low, perhaps influenced by the group format.  Still, trauma symptoms largely persisted, suggested that a trauma focused treatment might be considered as a concluding step to CA CBT. 

Regarding the lack of culturally-adapted treatments for refugees, we hope our findings might encourage practitioners to implement CA CBT into their technical repertoire. Also, we want to point out for all German speaking readers, that the CA CBT manual for Arabic and Farsi speaking refugees was published recently, containing material in both languages (Stangier, Kananian, Yehya, & Hinton).

Reference Articles

Kananian, S., Soltani, Y., Hinton, D.E. & Stangier, U. (2020). Culturally adapted CBT plus Problem-management therapy with Afghan refugees: A randomized controlled trial. Journal of Traumatic Stress.

Stangier, U., Kananian, S., Yehya, M., & Hinton, D. (2020). Kulturell adaptierte Verhaltenstherapie für Menschen mit Fluchterfahrung: Manual zur Stärkung von Resilienz und innerer Ausgeglichenheit. Weinheim: Beltz

Discussion Questions

  1. How can these adaptations broadly be implemented into a National Health Care system? 
  2. What are potential considerations to reduce post migration stressors at an early state, shortly after refugees arrive in the respective host country? 
  3. Should transdiagnostic approaches like CA CBT (which don’t primarily focus on one disorder, but on several subclinical syndromes and also on resilience) be considered as a general procedure, not only for refugees, but also for Western patients from Europe and USA?

About the Authors

Schahryar Kananian, M. Sc., is a research assistant at the faculty for Clinical Psychology at the Goethe-University Frankfurt. His research interests are cultural adaptations of CBT interventions. The adaptations were mainly based on protocols from Devon Hinton. His research seeks to reduce the barriers for refugees to receive psychological treatment and support. 

Yasaman Soltani, M.Sc., is a licensed clinical psychologist (CBT) working in Frankfurt, Germany. Her research interests include cultural dimensions of psychotherapy and acculturation processes of immigrants living in Germany. Currently, she is finishing her PhD on acculturation in adult and child immigrant populations living in Germany and working as a therapist at her own private practice."

Devon E. Hinton, Ph.D., is a psychiatrist and medical anthropologist, and is Associate Professor of Psychiatry at Harvard Medical School and Massachusetts General Hospital. He originally developed Culturally-adapted CBT and adapted it for several subgroups such as for refugees from Cambodia, Vietnam and Latin America.  His further research interests include cultural aspects of sleep paralysis and key idioms of distress. 

Ulrich Stangier, Ph.D. is a Professor of Clinical Psychology at Goethe-University. He conducted the adaptation of CA CBT for Arabic and Farsi speaking refugees. Further research interests include Social Anxiety Disorder, loving-kindness meditation as an intervention patients with chronic depression, and Body dysmorphic disorder. 

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